GW1-2022-09011_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Con
tractor
Information:
/�Ij�
�' "L.DDVhPit i 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A-IVC YF v
ft. ft, i
I
NC Well Contractor Certification Number C p D J �(1�? 15.OUTER CASING for multi-cased wells OR LINER if a licable
Cascade Drilling, LP J r l� FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Conipany Name ` "'
D%'%i 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,County.State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): tt. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. tt. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: -7-1 ft. ® ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if app licable
❑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)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock e,grain size,etc.)
tt. ft.
4.Date Well(s)Completed:6/D-3"1- Well ID# /pz -7 R. R. r
5a.Well Location: b0�
^ Duke Energy
.-zility/Owner Name Facility lD#(ifapplicable) ft. fL
306 Dunnaway Road, Semora, NC 27343
Physical Address,City,and Zip
rt. rt.
Gaston 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
N W - jf �Z
6.Is(are)the well(s)• ❑Permanent or f5Temporary Signature of Certified Well Contracto Date
By signing this form.1 herebv certifv that the wells)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
ll'this is a repair,fill out known well construction information and explain the nature of'the oJthis record has been provided to the well owner.
repair under#21 remarks section or on the back at this form.
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: -7 -) (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths lf'different(example-3(c.)200'and 2L100')
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
Ifwater level is above casing,use"+-
11.Borehole diameter: (in,) 24b. For Injection Wells:Copy(to,DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NCk 27699-1636
12.Well construction method: SO/'/c 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
)R WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) Method of test:
i
13b.Disinfection type: Amount: I
Fonn GW-1 North Carolina Departinent of Environmental Quality-Division of Water Resources Revised 6-6-2018