GW1-2023-00625_Well Construction - GW1_20230105

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
1.Well Contractor Information:
NICHOLAS HAYES 14.WATERZONES
Well Contractor Name FROM TO I DESCRIPTION
ft. ft.
A - 4121
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells)OR LINER if a rlicable
GEOLOGIC EXPLORATION FROM To DIAMETERI ! THICKNESS MATERIAL
. -Company Name 0.0 ft. 71.0 ft. 8.0 lint, SCH 80 PVC
16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#: WR0300123 FROM TO DIAMETER!- THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,!/ariance,etc.) ft. ft. 'in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.FROMSCREENTO DIAMETER {SLOT SIZE THICKNESS bATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL, EMPLACENI ENT M ETHOD&AMOUNT
Non-Water Supply Well: 0.0 f` 71.0 It- NEAT PORTLAND CEMENT SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licablc
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
❑Geothennal(Heating/Cooling Return) OOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0.0 It- 23.0 ft- BROWN SANDY SILT
4.Date Well(s)Completed: 1 0/1 8/22 Well ID# EX-32BR 23.0 ft 25.0 ft ROCK
5a.Well Location: 25.0 ft 30.0 ff BROWN SANDY SILT
DUKE ENERGY OF THE CAROLINAS MARSHALL STEAM STATION 30.0 ft- 50.0 ft- PWR
Facility/Owner Name Facility IDtl(ifapplicable) 50.0 ft 57.0 ff WEATHERED ROCK
8320 NC HIGHWAY 150 SHERRILLS FORD 28673 57.0 ft 251.0 ft ROCK
Physical Address,City,and Zip ft. ft.
CATAWBA 461803426350 21.REMARKS
County Parcel Identification.No.(PIN) OPEN HOLE
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: �WIAI`rl35° 35' 40.53" N 80° 57' S5.761' �� 12/14/22
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor i Date
By signing this form,I hereby certify that the 4ell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 29No 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
lf'lhis is a repair,Jill out known well construction hijbi-ntaiton and explain the nature of the ofthis record has been provided to due well owner. / '' I i',j r
repair under k21 remarks section a•on the back of 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 additiort�Nll ory�tru��nfo
construction,only 1 GW-I is needed. indicate TOTAL NUMBER of wells (add'See Ovet in Remarks Box).You may also attach ad(�itional ages e sary.
drilled: 24.SUBMITTAL INSTRUCTIONS •.
251.0 �1�:� =_l�'OG
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of«'ell completion per the following:
For multiple wells list all depths ifd &rent(eraniple-3 rr 200'and 2 a 100')
17.5 24a. For All Wells: Original form to Division of Water Resources (DWR),
If irater/ere/is abm e casing,use
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 16.0/7.0/12.0 (in)
Program, 1636 MSC,Raleigh,NC 2769I9-1636
12.Well construction method: AUGER/AIR ROTARY
24c.For Water Supply and Open-Loon 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(.-pm) Method of test:
13b.Disinfection type: Amount:
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Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2015