GW1-2022-08643_Well Construction - GW1_20220427

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 2581
ft. tr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a rlicaIle,
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS Ile,
ME
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
LLst all applicable Irel/construction permits(i.e.UIC,County,State.Variance,etc.) 0.0 ft. 8.0 ft. 6.0 in• .188 STAINLESS STEEL
3.Well Use(check well use): rt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 8.0 ft. 43.0 ft' 6.0 in. .010 .188 STAINLESS STEEL
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. tt, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fr• 1.0 fr. AQUA GUARD SLURRY
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft• 46.0 fr' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control 46.0 fr• 53.0 fr' 20-40 FINE SILICA SAND
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,ginin sae,etc.)
0.0 fr• 14.0 fr• BROWN SILTY SAND
4.Date Well(s)Completed: 02/18/22 Well ID# EX-AS-10 14.0 ft. 26.0 f1• PWR
ia.Well Location: 26.0 fr' 46.0 fr' ROCK
CLIFFSIDE STEAM STATION
Facility/Owner Name Facility ID#(if applicable) ft. ft.
t�,tea r>n
573 DUKE POWER ROAD MOORESBORO 28114 rt. ft. �;' ,� . `'_1-y
Physical Address,City,and Zip ft. ft.
RUTH ERFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL 1.0 21.0 FEET/•S,U.MP�,.,Q.3,0-44.0 FEET
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees: e
(if well field,one IaUlong is sufficient) 22.Certification-
(if
12' 51.93" N 81° 45' 11.11" , ( 03/23/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
Rr signing this./brit,I hereby c•erlifj,that the u•eh(s)u•as(here)constructed is accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC'WC.0200 We//Consa uctiott J'tandnrdr mu/that a copy
Ifdtis is repair,fill out known well c•onetruc•tion information and erpiain the nann•e t f'the of'dtis record has been provided to the Ire/1 owner.
repair under 21 renmrkv section m•on the back ofthis firm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW 1 is needed. Indicate TOTAL NUMBER of we I (add'See Over in Remarks Box).You may also attach additional pages if necessary.
I s
drilled:
24.SUBMITTAL INSTRUCTIONS
0
9.Total well depth below land surface: 44. (ft.) Submit this GW-1 within 30 •days of well completion per the following
For multiple Ire//r list all depths iJdiffcrenl(exm nnple-3 200'and 2(t��t 100) )� p d•
11.53 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
ll uwer lore/is abore casing,use"+'
11.Borehole diameter: 16•0/6•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/AIR
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
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
I
Form GW-I North Carolina Department or Environmental Quality-Division of Water Resources Revised 6-6-2018