GW1-2022-08650_Well Construction - GW1_20220427

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Inforrnalion:
NICHOLAS HAYES 14.1VATERZONES
Well Contractor Name FROM TO DESCRIPTION
R fr
A - 4121
NC Well Contracior Certification Number 15.OUTER CASING for nulAawlsOR L,KELIfalleable
GEOLOGIC EXPLORATION FROM To R TRC `
MATERIAL
H. ft. is
Company Nainc
16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit 4: FROM TO DIAht VrER THICKNESS MATERIAL
lasr all applicable well construction perotirs(i.e.I1/C,Com:Oc State.Irarionce,etc•.) 0.0 ft. 5.0 IL 2.0 .in. SCH 40 PVC
3.Well Use(check well use): n. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE 71itCKNESS htATERIAt
OAgricultuml OMunicipal/Public 5.0 rt. 7.0 ft. 2.0 in, .010 SCH 40 PVC
❑Geothermal(Ileating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in
❑Industrial/Commercial OResidential Water Supply(shared) 18,GROUT
Oirrigation ❑Wells> 100,000GPD FROM TO MATERIAL Eh1P1ACEhtvfrmuitoD6AmouNT
Non-Water Supply Well: 0.0 f- 3.0 f' AQUA GUARD SLURRY
MMonitoring ORecovery n. h.
Injection Well:
OAquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK If a licable)
❑Aquifer Storage and Recovery OSalinity Barrier FRO51 TO MATERIAL EDMPLACEIIE,YTAIEfHOD
❑Aquifer Test ❑Stormwatcr Drainage 4.0 f'- 7.0 f' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheens if necessary)
OGeothermal(Heat in Coolie Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,toillrack type,Z rain sire,etc.
0.0 f' 5.0 R RED SILTY CLAY
4.Date Well(s)Completed: 12/20/21 WelllDN PMW-AS-6D 5.0 n. 7.0 D ROCK
Sa.1Ye11 Location:
ft. ft.
CLIFFSIDE STEAM STATION rt. R.
Facilitylthvner Name Facility IDW(il'applicable) rt. ft.
573 DUKE POWER ROAD MOORESBORO 28114 ft. ft.
Physical Address,City.and Zip
ft. 1111. .. a
RUTHERFORD 21.REMARKS ADD 709
County Parcel Identification No.(PIN) BENTONITE SEAL 3.0-4.0 FEET
,r,�a
Sb.Lalitude and longitude in degrees/minutes/seconds or decimal degrees: is t�jn-f ml'
^:: �,
(dwell field,one[at/long is sufficient) ' { I�J�rt_Jv;i l JI;.
22.Certification: t,'��•t.
350 12'48.01" N 810 45' 12.11" W
i 03/23/22
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature
of Certified Well Contractor Date
R}.signing thus fitrnt I hereby cerfify that dre:rell(r)was(were)consin¢Yed in orcordanre 10th
7.Is this a repair to an existing well: ❑Yes or (5No 15A N('AC-02C 0100 or 15A NC A('OX,0200 Well Canstrrtcrion SiatulanA attd that a cope
if this is a repair•till am known well cattsiruriion ii fhrmotiiyti and explain the nantre cJ7he t jilts reconh has been provided to the well writer.
repair under=21 rentar.E_c.rection or on the hack ofihi.r form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT of-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'Sec Over'in Remarks Box) You may also attach additional pages if necessan
drilled 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7'0 (ft
hiir nudaple ire/lr list oll depths ifdif/erent(exar ple•3r4,200-and 2_A1&)') ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below lop of easing: 4.0 (ft.) 24a. For All Wells: Original form to Division or Water Resources (DWR).
1)water level is abore caring.rise--" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.0 (in_) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(II.'C)
Program,1636 MSC.Raleigh,NC 27699-1636
12,Weil construction method: SONIC
24c.For Water Supply and Open-Loop Geothermal Return-Wells:Copy to the
(ix auger,rotary.cable,direct push,etc.) county environmental health department of the county where in e
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells rocl over 100 000 GPD:Copy to DWR,CCPCUA
\ Permit Program•Ibl I MS ,Ra e:g ,N 27 161 I
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
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Forth G WA North Carolina Deportment of Fnvironmentat Quality-Division or Water Resources I Revised(r6 2013