GW1-2022-08665_Well Construction - GW1_20220510

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT I ,
74.WATER<ZONES. ) •
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4226 ft. fr. K
NC Well Contractor Certification Number 15.OUTER CASING for tuuh i-cased;wells.OR.LINER if a' livable
GEOLOGIC EXPLORATION FROM TO DIAMETER! THICKNESS MATERIAL
Company Name ft. ft. I in.
16.INNER CASING OR TUBING(geothermal closed-too '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 70.0 rt• 2.0 In' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN `
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 70.0 ft' 80.0 ft' 2.0 "" .010 SCH 40 PVC*
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.l
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ".
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 57.0 ft- AQUAGUARD SLURRY
(EMonitoring ❑Recovery
Injection Well: ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 65.0 ft• 80.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20 DRILLING LOG attach additional sheets if necessary)
❑Gcothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck e, rain sin,etc.
0.0 ft• 1.0 fr• GRASS/TOPSOIL
4.Date Well(s)Completed: 04/27/22 Well ID# CCR-5BR 1.0 e. 11.0 ft• BROWN SILTY CLAY
5a.Well Location: 11.0 ft' 28.0 rt• BROWN SILTY PWR
CLIFFSIDE STEAM STATION 28.0 ft• 80.0 fr• WHITE/GRAY ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
573 DUKE POWER ROAD MOORESBORO 28114 ft. ft.
Physical Address,City,and Zip ft. ft.
RUTHERFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-57.0-65.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***U-PACK***
(if well field,one lat/long is sufficient) 22.Certification:
350 12' 50.14" N 810 45' 14.22" W 05/02/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certt&that the trell( rg.LCopGGG�333s����tr�+++u���fifiI din accordance with
7.Is this a repair to an existing well: ❑Yes or IENo 15A NCAC 01C.0100 or 15A NCAC 02C'.0200 t uc 6s �a copy
/jthis is a repair,fill out known well construction information and explain the nature oJ'the of this record has been provided to the well ovne
repair underr.•'2!remarks section or on the back ofthtsJorm. h�I�Y �0 � _
23.Site diagram or additional well details: a d O 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide' tlon I ell ction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You ma alsv atta ad%onnaI pa es if rllecessar�'.
drilled: 24.SUBMITTAL INSTRUCTIONS �+� U
9.Total well depth below land surface: 80'0 (ft.)
Far multiple wells list all depths ijdiiffereni(example-3@200'and 1@/00') Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: 18.0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
/jwater/stet is above casing,use"+"
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(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12,Well construction method:
SONIC
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 ov'er>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:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018