GW1-2022-08639_Well Construction - GW1_20220510

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: k
KENNY SARGENT 14.WATER•ZONEs .:
Well Contractor Name FROM TO DESCRIPTION
ft. ft. I
A - 4226 ft. ft. !E
NC Well Contractor Certification Number 15.OUTER CASING formulti-cased wells OR LINER if a linable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
R. ft. j 'in.
Company Name
16..INNER CASING OR TUBING 4eotbeemal closed-loop)
2.Well Construction Permit#: FROM TTO DIAMETER THICKNESS I MATERIAL
List all applicable trell construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft. 55.0 ft- 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 55.0 It- 65.0 ft' 2.0 in' .010 SCH 40 PVC*
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:.GROUT
❑i r'I ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 42.0 ft. AQUAGUARD SLURRY
OMonitoring ❑Recovery R. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 50.0 ft• 70.0 ff' 20-46 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,soit/mck type,gnin size,etc.
0.0 ft- 10 ft. WOODS/TOPSOIL
4.Date Well(s)Completed: 04/18/22 Well ID# CCR-13BR 1.0 ft. 6.0 fL BROWN SILTY CLAY
5a.Well Location: 6.0 ft, 1 ido It. BROWN SILTY PWR
CLIFFSIDE STEAM STATION 11.0 ft- 70.0 l" WHITE/GRAY ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
573 DUKE POWER ROAD MOORESBORO 28114
Physical Address,City,and Zip ft. ft.
RUTHERFORD 21.REMARKS
County Parcel Identification No.(PiN) BENTONITE SEAL 42.0-50.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***U-PACK***
(if well field,one tat/long is sufficient) 22.Certification:
350 12' 51.43" N 810 45' 10.74" W #,u,. -d-'/�• ��_ 05/02/22
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby cer(ify that the u"ell(.)ivas here constructed in accordance irith
r,
7.Is this a repair to an existingwell: ❑Yes or 15No 15A NCAC 02C'.0100 or 15A NCAC 01C!.0200 Well �
S n a
if this is a repair,Jill out known well construction information and explain the nature oJ7he of this record has been provided to the ire/l owner.
repair under'2/remarks.rection or on the back of this Jbrm. 23.Site diagram or additional well'details �� �/ (� �n
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide addilF&ni will c�nMiZn info
construction,only I GW-i is needed. Indicate TOTAL NUMBER of Nvells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: hftowbon Pry Unit
24.SUBMITTAL INSTRUCTIONS MVQGOG
9.Total well depth below land surface: 65.0 (ft•
Far multiple wells list all depths tfdii ferent(example-3@200'and 2@100') ) Submit this GW-1 within 30 days of well completion per the following:
35.0 24a. For All Wells: Original forrt to Division of Water Resources (DWR),
/J'u a(er level is above casing,use"i
1 Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.0 (in) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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
i
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 27699-1 61 1
13b.Disinfection type: Amount:
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018