GW1-2022-06279_Well Construction - GW1_20220608

WELL CONSTRUCTION RE,CORAD For Internal List ONLY
This form can be used for singie nr mullipte%vclls
1.Well Contractor Information: ---
1-4.AWATERTER Z01F.S 1
Robert Stevens FROM To . D_ESMPTI)x -
Vicil Contractor Nanic ft. fL
f rt.
NC Well Contractor Cent$cation Number- 15.OUTER CASING(for motfi-cased wells)OR L11ER(if a licable)
FRblf 'IO DL\1tETEH THI(:fitvFSS NUTERLLL.
Cascade Drilling - Ft. fL -
Company Name 16.INNER CASING OR T'DING(geothermal clnsed-loo )
F 6.11 -ro _ DULMLTER TRIMNESS MATERIAL
2.1Well Construction Permit M_ _ _ _ 0 fL 59 0 fL 2.0 '" SCh 40 PVC
List all applicable yell permitx(ix,('+,trots•,.gore, 'rnriance,hfectlnn,etc.) -- -
ft. fL in.
3.'Well Use(check well use): 17.SCREEN
- ---Writer Supply FROM TO DIANIFTER SLOT SIZE -THICKNESS MATERINL
\\cU
❑Azricultural ❑Municipal Public 59.3 f` 64.3 ff' 2.0 m- .010 SCh 40 PVC
OGcothemial(FIeatinglCooling,Supply) OResidential NVater Supply(single) fL ft.
OlndustrialiCommercial 1;111csidential Water Supply(shared) 18,GROUT
FROM TO '1LVTERIAL F11P1.,1C.E}I F1T lSFTHOD S%AOtOIiT."r
Dirigation 0 fL 533 Fft- Portland Tremie
Non-\Water Supply Well: -
f`aMonitorinn ORccover 53.3 157,0 TL (3entonite Poured
Injection 1\'01: rL
(3Aquifer Recharge 0(iroundvaler Remediation 19.SAND/GIL VELPACKIirn licable)
` FRONT TO MATERIAL @,IMACElIE.NTMLTHOD
0A uifer Storagge and Recovery ❑Salinity Barrier
y 57.0 f` 65.5 rL 42 Sand Poured
O:+.quifer Test OStomt\tater Drainage
fL 1't.
LlExperimental Technology L'Subsidence Control 20-DRILLING LOG an uh additional sheets if necrSsarS')
oGeothermal(Closed Loop) OTracer Mom TO J>ESCRIP7 tp� <o)nr.kanlnesa soivrnektY i, sin s'vt etc.
❑Geothermal(i leatinJCooling Return) GiOther(explain under821 Remarks) 0 fL - ft
4128/16 CCR-FGD-10DA __ fL ft.
4.Onte Well(s)Completed: \1'eU IDS fL ft. -
i
i;t.Well Location: fL fL -'
Duke Znetgy-Eeievis Creek Steam Station fL ft. -
Facility,'OwaerName Facility IM;E(ifapplicable) ft rr- 8 ,
3195 Pine Hall Road, Belews Creek, NC 27009 fL --�ft v
Physical Address.City,mud Zip Zt.RGiMARKS -
Stokes f 1 Lm A'rlID'R
Coo„n. Parcel ldentification'to.(PIN)
ib.Latitude and Longitude is dereeslminutes/seconds or decimal degrees: 22.Certification: ;-
(if%cell field.one tattlong is sufficient) _ l
36,252949 N 80.098877 %W _ - ., ~_
Signati'Nt of Ccrtihc<!Wc11 C'nnrcatwr - Date
6.Is(are)the sI'ell(s); 1APermanent or OTemporary )Sy.sigwng tins janq l herchr cert(fv riot tl),mW(%)ono('re")consimcred in accmrdanre
u•irl+!iit�('.-I('fl?C.ql UU or 1.'+.4:Y('AC'!1?<'.U20U;Ye!!('nacrructinn Soodard,tmd Mat a
7.Is this a repair to on existing well: E]Ycs or 0No copy nfrhis scrod ltos heen provided ro ilia irell owner.
4111rty is a repair fill n111.0roun well conatrucliom h,run,tatiarr and explain the Dantre ajthc
repair wader;2l remarks section or on ilia hack nfthis Inuit. 23.Site diagram or additional well details:
You may use the back ofthis pane to;provide additional well site details or v.ell
S.;Number of wells constructed: construction details You may also attach additional pages if necessary.
Far-duple inJncrinu nr rani-x•otrr supply rrelA MI,i"+rhh rhe.some c-oractian,....can
.wbmir arc jtrm. SUBMIT7:AI,INSTGCTIOtYS
64.3 2.a. For .all Wells: Submit this form ctiithin 30 days s of completion of well
9."fotat well depth below land surface: (ft.) P
V.ar ondople ,ellx Ibi all dgwh,!f(Ii(Jemot 6-mple-3Co200'and 2?iHuf)') construction to the:foilov ing;
10.Static water level below top of casii>r• 60-2 (ft) Division of Water Resources,information Processing UniL
if>.-atcr level is ahorc casing,occ" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 9•24 (in.) 24b.For lnicction',Veils ONLY: In addition to sending the form to the address in
Sonic 24a above, also submit a copy of this form Within 30 days of completion of.aril;
12.NVell construction method- -� constmction to the follo\ring-
(i.c_auger,rotan•,cable.direct push,arc.) Division ofWVater Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY, 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection\i'efls:
13a.Yield(gpm)------ -_ Method of test: -- Also submit one copy of this fonn'within 30 dads of completion of
Amount: well constniction to the county health department of the county where
constructed.
Form GeV-I Nordi Carniina Department of Environment and Natunl Rcnourcc;-Division of Water Resources Reused Acura 20 i