GW1-2022-08647_Well Construction - GW1_20220427

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 2581
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mull;-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. I ft. in.
Company Name
16.INNER CASING OR TUBING etithermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction peruits(i.e.UIC,Cou ly,Stale, Variance,etc.) 0.0 ft. 11.0 ft. 6.0 in' .188 STAINLESS STEEL
3.Well Use(check well use): ft. ft. in.
Supply Well: 17.SCREEN
Water Su
PP FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑AgricL1ltural ❑Municipal/Public 11.0 ft' 26.0 ft. 6.0 in.
.010 .188 STAINLESS STEEL
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in•
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 1.0 ft. AQUA GUARD SLURRY
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑AquifcrTest ❑StormwaterDrainage 5.0 ft• 27.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geotlermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soilhvck e, rain sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0.0 ft• 12.0 ft. RED/BROWN SILTY CLAY
4.Date Well(s)Completed: 02/17/22 Well ID# EX-AS-13 120 rt. 270 fl. ROCK
Sa.Well Location:
CLIFFSIDE STEAM STATION ft. ft.
Facility/Owner Name Facility Ina(ifapplicable) ft. ft.
573 DUKE POWER ROAD MOORESBORO 28114 rt. rt. Cam+ ' ° .poll^ )
Physical Address,City,and Zip ft. ft. APR 2 7
.2029
RUTHERFORD 21.RENIARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 1.0-5.0 FEET/SUM '.-;?2`fi;4•t2,7,:0 FEET
��`�V"�'ra�llLri�F�'i1+.)�� rviloJflb-li
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell Geld,one tat/long is sufficient) 22.Certification:
350 12' 51.90" N 810 45' 11.58" W c .. �J -- 03/23/22
6.Is(are)the well(s)• INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this frrrni,l hereby certifi,Thal the irell(r)eras(urre)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
I/7his is a repair.Jill oul known ire//conxlrac lion iii/brinalion and explain the nature of the ofllds record has been provided to tire ire//oirner.
repair under r 21 rentorkv section or au the back oJ'Ihis form.
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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBi1'IITTAL INSTRUCTIONS
9.Total well depth below land surface: 27.0 (ft.)
I.or Inulliple yells list all depths?/'different(erm anple-1 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
12.94 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
if n,aler level is above cae/»g,ruse"...
11.Borehole diameter: 1 6.0/6.0 (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:Copp 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 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018