GW1-2023-00642_Well Construction - GW1_20230105

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: l
I.Well Contractor Information: i
NICHOLAS HAYES 14.WATERZONES
Well Contractor Name FRONI TO I DESCRIPTION
1
A - 4121 ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if a licahlc
GEOLOGIC EXPLORATION FROM TO DIAMETER' THICKNESS MATERIAL
ft. ft. in.
Company Name
WI0300437 16.INNER CASING OR TUBING eothermal closed-loo t
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County.Slate,flariance,etc.) 0.0 ft, 40.0 ft• 6.0 - in. SCH 80 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICINESS MATERIAL
❑Agricultural ❑Municipal/Public 40.0 ft' 105.0 ft. 6.0 in. .010 SCH 80 SS
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. R. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irfigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 35.0 ft' NEAT PORTLAND CEMENT SLURRY(PUMP)
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 35.0 ft, 38.0 tr. 16-50(#1) POUR
❑Experimental Technology ❑Subsidence Control 38.0 ft, 106.0 tr, 7-35 (#2) POUR
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG'attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) PJOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soitlrock type.grain size,etc.
0.0 ft. 700 fr. BROWN SILTY SAND
4.Date Well(s)Completed: 07/15/22 Well ID# IN-1 70.0 tr• 85.0 fr. PWR
Sa.Well Location: 85.0 fr• 91.0 ff WEATHERED ROCK
DUKE ENERGY OF THE CAROLINAS MARSHALL STEAM STATION 91.0 fr• 106.0 fr. ROCK
Facility/Owner Name Facility ID9(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) **`INFILTRATION***
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
STAINLESS STEEL SUMP- 105.0- 106.0 FEET
(if well field,one lat/long is sufficient) 22.Certification:
350 35' 41.26" N 800 57' 57.33" W � � 08/23/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
Hy signing 11is(brnt,I hereby certify that the trell(s)was(irere)constructed in accordance it
7.Is this a repair to an existing well: ❑Yes or MNo I5A NCAC 02C.0100 or I5A NCAC 01C.0200 Well Construction Standards and that a copy
/('this is a repair,Jill our knoun well construction hijbrmation and explain the nature of the o('this record has been provided to the well owner.
repair under=21 remarks section or on the back o('this jorin.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page 4o provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach ad�ditio'naPpabeeS?ifneees�ar},.,
drilled:
24.SUBMITTAL INSTRUCTIONS e
9.Total well depth below land surface: 106.0 (ft) IaI\I w n ,�n��
Vor nuthiple wells list all depths y'cli(Jerew(example-5@1r/0'and 1 tt!00') Submit this GW-i within 30 days of well completion perJt l g• 1.1
10.Static water level below top of casing: 64.0 (ft) 24a. For All Wells: Original form to Division 16fi lVate> 1te$q�i tees-( It�,Ut�t
/('water level is above cashktf,use••+" information Processing Unit,1617 rviSC,Raleigh,NC 27699-%1310jBIOCZ
11.Borehole diameter: 14.0 (1n) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ANGER/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
13a.field(gpm) D4ethod of test:
Permit Program, 1611 MSC,Raleigh.,NC 2 7699-1 61 1
�
13b.Disinfection type: Amount: l'
f
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources r Revised 6-6-201 S
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