GW1-2022-08652_Well Construction - GW1_20220427

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft.
A - 4121 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS \7.4TERIAL
rt. ft in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perudts(i.e.Cl1C,Counryt State,I%arionc•e,etc.) 0.0 ft. 28.0 ft. 6.0 in. .188 STAINLESS STEEL
3.Well Use,(check well use): ft. R. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 28.0 ft. 108.0 ft. 6.0 �,n .010 .188 STAINLESS STEEL
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑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 ft- 18.0 ft• AQUA GUARD SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge MGroundwater Renediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 23.0 ft• 109.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION color,hardness,soil/rock tyre, chin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
0.0 rt. 89.0 rt. PW R
4.Date Well(s)Completed: 02/11/22 Well ID# EX-AS-1 89.0 rt. 109.0 ft. ROCK
R.
ia.Well Location: ft.
CLIFFSIDE STEAM STATION
Facility/Owner Name Facility ID#(if applicable) ft. ft.
573 DUKE POWER ROAD MOORESBORO 28114 rt. ft.
Physical Address,City,and Zip ft. rt. a �
RUTHERFORD 21.REMARKSf ,!
County Parcel Identification No.(PIN) BENTONITE SEAL- 18.0-2 E MP- 108.0-109.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irwell field,One IaVlOng is Sufficient) 22.Certification' tAX
350 12' 47.50" N 810 45' 12.44" 1V "d"d' T�r'r ����u'i(n;;;03/23/22��C%y"
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By sigoiag thisflirm,/hereby cerl/Jj,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A,NCAC 02C.0200 17'ell Construction Standards and that a copj-
!f this is a repair,fill our known ire/1 construe con in/7u•nration and explain the nature afthe n%tbis record has been provided to the well owner.
repair under r.2l remarks section or on the back of this for•nr.
23.Site diagram or additional well details:
S.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 wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
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9.Total well,ell depth below land surface: ' (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple ire//s list all depthsifdJjeruv(c,xnurple-3C_,00'nnrl_«l00') P P g
53.48 24a. For All Wells: Original forth to Division of Water Resources (DWR),
10.Static water level below top of casing:!l u•nter level is abate casing.use'? (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
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/AUGER/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 orthe county where installed
FOR\PATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.field(gpnt) Method of test: Penn it Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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