GW1-2023-00652_Well Construction - GW1_20230105

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A - 4121
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased,well's OR LINER if a livable)
GEOLOGIC EXPLORATION 'FROM TO DIAMETER4 I THICKNESS MATERIAL
0.0 ft- 81.0 ft- 8.0 !in. SCH 80 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WR0300123 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.) ft. ft. 'in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER :SLOT SIZE THICKNESS MATERIA
❑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
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL' EhIPLACEIIIENTTt ETHOD&ADIOUN'T
Non-Water Supply Well: 0.0 ft. 81.0 ft- NEAT PORTLAND CEMENT SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK_if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stornnwater Drainage ft. fr.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soilh•ock e,grain size;etc.)
❑Geothermal(Heating/Cooling Return) CJOther(explain under 921 Remarks)
0.0 ft• 55.0 ft. BROWN SANDY SILT
4.Date Well(s)Completed. 10/20/22 Well ID# EX-36BR 55.0 ft• 70.0 f` PWR
5a.Well Location: 70.0 ft' 254.0 ft. ROCK
DUKE ENERGY OF THE CAROLINAS MARSHALL STEAM STATION
Facility/Owner Name Facility ID#(if applicable) ft. ft.
8320 NC HIGHWAY 150 SHERRILLS FORD 28673 ft. ft.
ft.
Physical Address,City,and Zip 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 lat11ong is sufficient) 22.Certification: f/
350 35' 40.85" N 800 57' S4.91" W �'`� 12/14/22
6.Is(are)the well(s): 09Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the roell(S)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or OtN`o hA NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standardv and that a copy
IJ7his is a repair,Jill out known well construction infin ntation and explain the nature of the ofthiv record has been provided to the well ou ner. _
repair under'-'2l remarks section or on the back ofthis fornn.
23.Site diagram or additional well details: s`2
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide addltaonal�Vell construction info
y (add'See Over'in Remarks Box).You may also attach ac�cbt' naVa s ssary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells J�� tJ �
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 254.0D� ° t` '
1•'or multiple wells list all depths ifd rent(exam rdple-3 00'and 2@100') Submit this GW-I within 30 days of well comllYBrfidiS'!?L�t el,
10.Static water level below top of casing: 24.04 24a, For All Wells: Original form to Division of Water Resources (DWR),
(ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
//'water lerel is above caving,use
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 27699-1636
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(-pin) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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