GW1-2022-04958_Well Construction - GW1_20220516

vv JVJa.L a,y1Na 1.R(U%_11V1N KL%I Vmm Ki W-1) For Internal Use Only:
1.Well Contractor Information:
F
James Hall 14.WATER ZONES 6
Well Contractor Name FROM TO DESCRiPTTOK
3224A ft. ft.
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NC Well Contractor Certification Number ft. ft.
IS.OUTER CASING for multi•cascd wctls OR LINER rf a ticable
Cascade Drilling FROM TO D1AML+TER TIiICKIYSS MATERIAI,
Company Name Mecklenburg County: #70002996 ft. ft.
i
16.INNER CASING OR TUDING facothermid closed4napl
2.Well Construction Permit#:NCDEQ: #WM0301193 FROM 'eo DIAMILTUR I •rtlrcicr ss I MA'rrRIAI,
List all applicable well construction pennies(i,e,UIC,Counly,Stale,Parlance.etc.) ft, t1fL
ill.
3.Well Use(check well use): ft. in.
W
ater Supply Well: 17.SCREEN
FROM 'rO UiAMIC11,11 st.o'rS17% 'I'HICKNKSS MATIMIAI,
Agricultural �Municipal/Public 2 in, .010 sch.4o
pvc
eothermal(Idcating/Cooling Supply) Residential Water Supply(single) ft. ft. In.
ndustrial/Commercial Residential Water Supply(shar'ed) 18,GROUT
orlon FROM TO MATERiAL EMPLACMIENT MrTOOT).k ANtOWIT
n-Water Supply Well: it. ft. bent grout tremmle
Recovery ft.
ection Well:
ft. ft.
Recharge Groundwater Remediation
oiler Store a and Reeove 19.SANA/GRAVEL PACK f n llcabla
q g ry [3SalinityBarrier FROM TO I MATERiAL rMPi.ACrKFNTMETiTOD
(Aquifer Test 0Stormwater Drainage PA ft. 1A trammle
Experimental Technology QiSubsidenee Control n. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG Which additional sheets K necessary)
Geothermal Heatin Coolin Return Other(explain under#21 Remarks) I FROM ft. To 009CRtPTiOK cator,hardn sell/rock type, rain size cdc
/ 11 � fr.
4.Nate Weil(s)Completed: r dd Well ID# �j'f!>i ft. ft.
50.Well Location: ft. ft.
Duke Energy It. R.
facility/Owner Name racility 1D11(if applicable) ft. ft. AAA t
13733 Lancaster Hy. Pineville NC ft. ft. �Y�/i 1
Physical Address,City,and Zip ft. ft. 00
L 21.RE,MARKS
County-- Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Ccrlificatio
N W 1 4-1 3-22
6.!s(are)the well(s)OPermanent or emporary Signatu CC fled Well Contractor Dato
fly si ' tints form,/hereby certify that ilia well(q)was(were)constructed tit aceordonee
7.Is this a repair to an existing well: Yes or xMNo with 15A NCdC 02C,D100 at-15A NCRC 02C.0200 Mali Construction Siandards and thal a
Iftlrfs is a repair fill out known well consotttion infrnnu Lion and explain the nature r f the copy of this record has been provided to the well owner.
repair•under#21 remarks section or on Ilia back aj'thisform, 23.Site diagram or additional well details:
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed, Indicate TOTAL NUMBER of wells construction details. You muy also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surfaces_ .� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nirdreplet arils list all depths if d?Oarent(exertnpla-M200'aad 2 Cal 1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing'Unit,
Y%voter level is above cusing,use"+" 1617 Mail Scrvico�Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 inch (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Sonic above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:
construction to the following
(i.e.auger,rotary,cable,direct push,etc.) .
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Ser•vicellCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water SUnnly&Into tion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction(to the county health department of the county
where constructed.
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