GW1-2022-09007_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.WAl Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
V 4
NC Well Contractor Certification Number �t 15.OUTER CASING for multi-cased wells OR LINER if a licable
Cascade Drilling, LP Sr P 202/ FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 111fw-miiau IC-) t f7'='• ,-rii?•7 J OFF
nt�.;.• 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.UIC.County.State. Variance,etc.) ft. ft. In•
3.Well Use(check well use): rt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ` ft' (6 ft' in. ��(G
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. + ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C)
(gMonitoring ❑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 3,C ft- I ft. I A
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
ft. ft.
4.Date Well(s)Completed:5 �'2 Well ID#A ?Z
Sa.Well Location:
rr. rt.
Duke Energy
_cility/Owner Name Facility ID#(ifapplicable) rt. ft.
306 Dunnaway Road, Semora, NC 27343
Physical Address,City,and Zip rt. ft
Gaston 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one[at/long is sufficient) 22.Certl ation:
N W
6.Is(are)the well(s)• ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date ,
Av signing this form,I herebv certii i,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair.Jill out known well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under#21 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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths iJ'diJferent(example-3@200'and 2@100')
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24a. For All Wells: Original fonts to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,161I7 MSC,Raleigh,NC 27699-1617
lfwater 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:-S-1114 /�Q 24c.For Water Supply and Op In;Loop Geothermal Return Wells:Copy to the
ti.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
)R WATER SUPPLY WELLS ONLY: 24d.For Water Wells produci g over 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:
Fonn GW-1 North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 6-6-2019
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