GW1-2022-08642_Well Construction - GW1_20220510

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
BRIAN THOMAS 1a:WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 2581
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casedwells ,OR LINER'if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER' THICKNESS MATERIAL
ft. ft. 1 in.
Company Name ,
16.INNER CASING OR TUBING `eothecmal closed-loon)'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Lis[all applicable hell construction permits(i.e. UIC,County,State,Variance,etc.) 0.0 f- 95.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): tt. tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER{ I SLOTSIZE I THICKNESS-1 MATERIAL
❑Agricultural ❑Municipal/Public 95.0 ft• 105.0 It' 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 "
❑lrrl atlon ❑Wel1S>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 83.0 ft- AQUAGUARD SLURRY
(EMonitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 91.0 tt• 105.0 tt• 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,soiUmck e, rain size,etc.
0.0 rt• 47.0 rt• TAN SILTY SAND
4.Date Well(s)Completed: 04/26/22 well ID# CCR-7DA 47.0 ft. 105.0 tt• PWR
5a.Well Location: tt, ft.
CLIFFSIDE STEAM STATION ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
573 DUKE POWER ROAD MOORESBORO 28114 ft. ft.
Physical Address,City,and Zip
fr. ft.
RUTHERFORD 21.REMARKs
County Parcel Identification No.(PIN) BENTONIfE SEAL-83.0-91.0 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' 51.44" 81° 45' 11.16" W !2Sr%;7-fir-- 05/02/22
6.Is(are)the well(s): (EPermanent or ❑Temporary Signature of Certified Well Contractor ! t as 9�(/�^'�'
By signing this form,1 hereby certify that the wells)was(vere tonsure a."dcc77PiTaD ith
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C;.0200 Well Con i n andar that a copy
If this is a repair,fill out known well conso•uction information and explain the nature of'the of this record has been provided to the well owner. 4 6zz
repair under°21 remarks section or on the back of this form. 23.Site diagram or additional well details- _,t�n'�+t�1
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to pro DUCHo1fltYro
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Yoti may also attach a if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
0
9.Total well depth below land surface: 105. (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2 a 100')
10.Static water level below top of casing 43.0 (ft) 24a• For All Wells: Original form to Division of Water Resources (DWR),
if water level is above caring,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6"0 (in.) 24b. For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 271699-1636
12.Well construction method: AIR 24c.For Water Supply and Open-T[oop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh;NC 2 7699-1 61 1
13a.Yield(gpm) Method of test:
i
13b.Disinfection type: Amount: j
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I�f! Revised 6-6-2018