GW1-2023-00654_Well Construction - GW1_20230105

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
NICHOLAS HAYES 1a.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. I I
A - 4121 k I
ft. ft. 1 {
t +
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased,wells OR'LINER if a licable)
GEOLOGIC EXPLORATION FROM TO DWMETER? THICKNESS MATERIAL
ft. ft. tn.
Company Name 1;
16.INNEWCASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WRO3001 23 FROM TO DIAMETER' THICKNESS MATERIAL
Lisi all applicable well construc•lion permits(i.e.UIC,County,State,1/6riance,etc.) 0.0 ft 65.0 ft' 6.0 t"' SCH 80 PVC
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER. SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 65.0 ft' 165.0 rt- 6.0 'n' .010 SCH 80 SS
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial -❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells-100,000 GPD FROM TO MATERIAL EMPLACEMENTiMETHOD&AMOUNT
Non-Water Supply Well: 0.0 f` 58.0 ft' NEAT PORTLAND CEMENT SLURRY
❑Monitoring ❑Recovery
Injection Well: ft: ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if alicableFROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 63.0 ft- 167.0 It- 20-46 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. It.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) OOther(explain under 421Remarks) ' FROM TO DESCRIPT ION color,hardness,soil/rocktype,ginin size,etc.)
0.0 ft 60.0 It-
GRAY SILT
4.Date Well(s)Completed: 09/14/22 Well ID# EX-10SBR 60.0 ft• 75.0 ft PWR
5a.Well Location: 75.0 rt. 79.0 ft' WEATHERED ROCK
DUKE ENERGY OF THE CAROLINAS MARSHALL STEAM STATION 79.0 ft 166.0 ft ROCK
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
8320 NC HIGHWAY 150 SHERRILLS FORD 28673 ft. ft.
fc
Physical Address,City,and Zip ft.
CATAWBA 461803426350 21.RUNIARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 58.0-63.0 FEET
STAINLESS STEEL SUMP- 165.0-166.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 22.Certification:
350 35' 41.26" N 800 57' 57.33" W 12/14/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature ofCertifled Well Contractor Date
By signing this form,1 hereby certify that fire wells)u•as(here)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or ITN0 I.iA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
Ifttis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under 21 remarks section or 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 ilo.preahide-ad itional wQtt-instruction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).Yoi,n a pats¢,atY�cri�-'a dfiio4Tf Lggl if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
166.0 ; JAN 0, 5'2023
9.Total well depth below land surface: (ft.)
(brmultiple,veils list al/depths ifdiiferent(example-3@200'a»d 2@l00') Submit this GW-1 within 30 days of well completion per the following:
37.0 24a. For All Wells: Original foTt�t'to f7lvts�on,-,•o.€e.Wgfer Resources (DWR),
fu•mer level is above casing,use 10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC'Raleigh; iti 27699-1617
!f "r"
11.Borehole,diameter: 14.0/10.0 (in) 24b. For Infection Wells: Copy tolpWR, Underground injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
AUGER/AIR ROTARY 1
.Well construction method: 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 ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh t NC 27699-1611
..
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018