GW1-2022-08645_Well Construction - GW1_20220510

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES,
Well Contractor Name FROM TO DESCRIPTION
A - 2581
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Iicable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. I ft. in.
Company Name
16ANNER CASING OR TUBING eothermal`closed-loo"
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) 0•0 ft- 40.0 ft- 2.0 rn. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Wafer Supply Well: 17.SCREENFROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 40.0 ft' 50.0 ft' 2.0 tn' .010 SCH 40 PVC*
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.'GROUT
❑irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 12.0 ft- AQUAGUARD SLURRY
(EMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a` licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 38.0 ft- 50.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control tr. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,suittrock type,gnin sin,etc.
0.0 ft- 13.0 ft• TAN SILTY SAND
4.Date Well(s)Completed: 04/14/22 WellID# CCR-15BR 13.0 it 21,0 ft• PWR
5a.Well Location: 21.0 tt' 50.0 "' ROCK
CLIFFSIDE STEAM STATION rt. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
573 DUKE POWER ROAD MOORESBORO 28114 ft. ft.
Physical Address,City,and Zip
RUTH ERFORD '21.REMARKS
County Parcel identification No.(PIN)
BENTONITE SEAL- 12.0-38.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
**"U-PACK***
(if well field,one lat/long is sufficient) 22.Certification:
350 12' 51.23" N 810 45' 11,27" w 05/02/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor j Date
By signing this form,1 hereby certify that the wells)eras(were c s n t frith
7.Is this a repair to an existing well: ❑Yes or I9No 15A NCAC 02C.0100 or ISA NCAC 01C.0200 We t do � t atpy
/f ids is a repair,fill out known ivel/construction infbrntation and explain the nature of the of this record ltas beenprovided m(ire well owner.
repair under"'21 remarks section or on the back oj'this form. 23.Site diagram or additional well details: pp'' � -{ nn 2�0�2�22
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page,to provide ad4itELI we constructioninfo
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach gddit emery.
ksoac
drilled: � �rA �
24.SUBMITTAL INSTRUCTIONS L� WvO
9.Total well depth below land surface: SO.O (ft.)
For multiple wells list all depths if different(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 21.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/1'water level is abore casing,use"=" i
il.Borehole diameter: 6.0 (in.) 24b. For Injection Wells:Copy tobWR,Underground injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
SONIC/HQ CORE 1
12.Well construction method: 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
13a,Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018