GW1-2022-09005_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD (GW-1) 1 For Internal Use Only:
1.Well ontractor Information:
14.WATER ZONES
Well Contractor Name -_ -..•' ' = _ q FROM TO DESCRIPTION
SF
Well Contractor Certification Number r r °' 2022 15.OUTER CASING for multi-cased wells OR LINER if a licable
Cascade Drilling, LP inrgY,�oF" FROM TO DIAMETER THICKNESS MATERIAL
in.
Company Name .1`i e',..R u'
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,CounA,,State. Variance,etc.) ft. ft, in.
3.Well Use(check well use): rt. rt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. R. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. rt. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
onitoring ❑Recovery
Injection Well:
ft. ft.
❑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
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Duke Energy
'cility/Owner Name Facility ID#(ifapplicable) ft. ft.
306 Dunnaway Road, Semora, NC 27343
Physical Address,City,and Zip ft. ft.
Gaston 21.REMARKS yy
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s)• ❑Permanent or ATemporary Signature of Certified Well Contractor, Date
bvsigning thisJorm,l herebv certijv that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
/J this is a repair,Jill out known well construction information and explain the nature oJ'the of this record has been provided to the well owner.
repair under#1/remarks section or on the back of this jorm.
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
constmction,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 depth below land surface: yS (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths it diJjerent(example-3@200'and 1@100')
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
/jwater level is above casing,use"+"
11.Borehole diameter (in.) 24b. For Injection Wells: Copy;to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 5 0 J;c 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
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�)R WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-161 1
See (�SYrf?oc Fob' /3�l� 1oQ<
13b.Disinfection type: Amount: E V�
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018