GW1-2022-08636_Well Construction - GW1_20220510

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT
'14i WATER ZONES.
Well Contractor Name FROM TO DESCRIPTIONft. ft. � '
A - 4226 R. fr. 1
NC Well Contractor Certification Number 15.OUTER.CASING for multi-cased"wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETERt THICKNESS MATERIAL
ft. ft. f in.
Company Name
16.INNER CASING OR TUBING 'eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 if 70.0 It. 2.0 1°' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN ;
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 70.0 ft. 80.0 ft' 2.0 tn' .010 SCH 40 PVC*
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
OIndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT.
❑Irrl atlon ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 57.6 ft. AQUAGUARD SLURRY
(EMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 65.4 it' 80.0 1` 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20 DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock rain size,etc.
0.0 It. 1.0 It. WOODSJOPSOIL
4.Date Well(s)Completed: 04/14/22 Well ID# CCR-4BR 1.0 ft. 14.0 It. BROWN SILTY CLAY
5a.Well Location: 14.0 It. 26.0 ft' BROWN SANDY SILT
CLIFFSIDE STEAM STATION 26.0 ft. 48.0 rt- BROWN SILTY PWR
Facility/Owner Name Facility ID#(if applicable) 48.0 It• 80.0 It. GRAY/WHITE ROCK
573 DUKE POWER ROAD MOORESBORO 28114 e. ft.
Physical Address,City,and Zip ft. R.
RUTHERFORD 11.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 57.6-65.4 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***U-PACK***
(if well field,one]at/long is sufficient) 22.Certification:
350 12' 51.16" N 81° 45' 09.71" W A,,,,,t li k-1-1 05/02/22
6.is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date��` fff
By signing this form,i hereby certify that the Well e co s l n with
7.Is this a repair to an existing well: ❑Yes or IENo ISA NCAC 02C.0100 or!SA NCAC 02C:0100 W 1 ons rue on an ar s tar a copy
If dnts is a repair,fill out known a-ell construction information and explain the nature of the of this record has been provided to the well owner. AA (� (�
repair under"21 remarks.section or on the back of this form. MAY 10 2022
23.Site diagram or additional well details:
i t t f this
k use the back o s page o pr v fo
may u c I
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You � 1
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may a-s iYnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 80.0 (ft.)
For multiple wells list all depths if'dierent(example-3@200'and 2 a 100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 50.0 (ff) 24a. For All Wells: Original form to Division of Water Resources (DWR),
//Ironer level is above casing,use" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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6.0 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over.100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh„NC 27699-1611
13b.Disinfection type: Amount:
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
is ,