GW1-2023-00624_Well Construction - GW1_20230105

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 4121
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for muRi-cased wells OR LINER if a tliSable)
GEOLOGIC EXPLORATION FROM TO DIAM ETERI I Tih E& MATERIAL
Company Name
0.0 ft• 1 60.0 ft. 8.0 SCH 80 PVC
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W R0300123 16.INNER CASING OR TUBING eothermal closed-loon)
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): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM . TO DIAMETER •'iSLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑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 TO MATERIAL EM PLACEMENT M ETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 60.0 ft" NEAT PORTIAND'CEMENT SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PAC K(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,q,;dn size,etc.)
❑Geothermal(Heating/Cooling Return) 110ther(explain under#21 Remarks).
0.0 ft. 35.0 1" BROWN SANDY SILT
4.Date Well(s)Completed: 10/18/22 Nell ID# EX-33BR 35.0 ft. 45.0 ft. PWR
ia.Well Location: 45.0 fc 49.0 ft' WEATHERED ROCK
DUKE ENERGY OF THE CAROLINAS MARSHALL STEAM STATION 49.0 ft. 250.0 ft. ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
8320 NC HIGHWAY 150 SHERRILLS FORD 28673 ft. ft.
Physical Address,City,and Zip ft. ft.
CATAWBA 461803426350 21.REMARKS
County Parcel Identification No.(PIN) OPEN HOLE
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 35' 40.58" N 800 57' 55.39" W � i 12/14/22
6.Is(are)the well(s): (EPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,l hereby ceriify that the we//(s)war(were)constructer)in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
!f thin is d repair,fill out known well construction information and explain the nature of the of this record has been provided to the well oivner.
repair under»21 reinarks-section or on the back of•this forin.
23.Site diagram or additional well details: p ,a
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to'provide addiliitDnllsveil�copStrl�etitbn i itoy
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wel Is (add'See Over'in Remarks Box).You rnay•also attach additional pages if
necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS JAN 0 5 L0L3
250.0
9.Total��welts Ust ell depth ab depthsI land
ifd surfj&rent(esanrp/e-3 n200'mrd 2 r 100') (f t.) Submit this GW-I within 30 days of well codirp1eYaon�iei i7te felfo�wrfi'g?�UMt
via e Q13,0G
15.0 24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing:If water level is above casing,use (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
'
11.Borehole diameter:
16.0/7.0/12.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1 636
12.Well construction method: AUGER/AIR ROTARY
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
1.
FOR 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:
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13b.Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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