GW1-2022-08666_Well Construction - GW1_20220427

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. ft.
A - 4121
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
rt. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Lis(all applicable irell construction permits(i.e.UIC,CounlY..S/ate,Variance,etc.) 0.0 rt. 11.0 ft. 6.0 in. .188 STAINLESS STEEL
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERI.\L
❑Agricultural ❑Municipal/Public 11.0 rt• 36.0 ft' 6.0 "' .010 .188 STAINLESS STEEL
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
❑Irrl atlon ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 1.0 ft. AQUA GUARD SLURRY
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge MGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 6.0 ft• 37.0 fL 20-4.0 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 type, rain size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
0.0 ft- 12.0 rL RED/BROWN SILTY CLAY
4.Date 1Vell(s)Completed: 02/1 7/22 well ID# EX-AS-12 12.0 ft- 37.0 ft. ROCK
Sa.Well Location: ft. ft.
CLIFFSIDE STEAM STATION
Facility/Owner Name Facility IDN(if applicable)
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- 1.0 6.0 FLEET%5 t(v1P "36:'0'`3 0 VEEP
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification: '
350 12' 51.85" N 81° 45' 13.26" W �'' ,� 03/23/22
6.Is(are)the\vell(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
Hp signing dti.v Joan,/hereby c•eri//y that the irellO iras(here)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or (ENo IjA NC'AC 02C•.0100 or 15.4 NCAC 02C.0200 Nell Construcdan Standards and that a copy
1/this is a repair.Jill out known we//construction hybrumiion and explain the nature ajlhe of•this record has been provided to the ire//owner.
repair wider t•21 remarks section or an the back a/'this fiirin.
23.Site diagram or additional well details:
b.For Geoprobc/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 (ad(I'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 37.0 (ftJ
pbr multiple ire//s list a/I depths ld/Q�rent(example-3 a?00'and 2 a I00') Submit this CW-I within 30 days of well completion per the following:
3.03 24a. For All Wells: Original form to Division of Water Resources (DWR),
1'u0.Static water level below top of casing: (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/flrater level is uhare caving.use..�..
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 of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.field(gpm) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Depaiment of Environmental Quality-Division of Water Resources Revised 6-6-2018