_Well Construction - GW1_20230327 (30)

WELL CONSTRUCTION RECORD(GW-1.) For Internal.Use Only:
1.Well Contractor Information:
B RA N DO N DOTY 14.WATER ZONES .
.. FROM TO DESCRIPTION
Well,Contractor Name
ft. ft.
A - 4595
fI. ft.
NC Well Contractor Certification Number 15.OUTER CASING foe multi=cased.'ivells OR LINER if.a tlicable)
GEOLOGIC EXPLORATION FROM . To DIAMETER! THICKNESS MATERIAL
0.0 [t• 80:0 ft• 6.0 ' 'in- SCH 40 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)'
2:Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well c'onsrriic•tion per,nits(i.e.UIC,County,State,Vdriance,etc.) 0.0 - rt• 85.0 rt',- - 10. in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.,SCREEN
FROM TO DIAMETER' SLOTSIZE THICKNESS MATERIAL _
❑Agricultural ❑Municipal/Public 85 d ft. 95.0 et: 2.0 to .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. et, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri,-ation ❑Wells>100,000GPD FROM, TO MATERIAL ENIPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 rt• 75.0 rt' PORTLANO BENTONITE SLURRY
In Monitoring ❑Recovery 0.0 ft. 800 .ft' PORTLANDBENTONITE SLURRY
injection Well: ft. ft.
❑Aquifer Recharge ❑Ground,.vater Remediation
19.SAND/GRAVEL PACK of a rlicable
❑Aquifer Storage and Recovery ❑Salinity Barrier. FROM.. TO MATERIAL ENIPLACEMENT.METHOD
❑Agditer Test ❑Stonmvater Drainage "82.0 ft- 95.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. fr.
❑Geother al(Closed Loop) ❑Tracer ' .20.DRILLING LOG attach additional sheets if necessa - "
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rack e,grain size,etc.
0.0 rt• 1.0 ft• ASPHALT/GRAVEL
4.D to Well(s)-completed: 03/10/23 Well ID# CCR-27D 1.0 rt• ,80.0 rt• BROWN SILT
-5a.N Yell Location: 80,0 ft- 95.0 ft- BROWN PWR
rt. rt.
ALLEN STEAM STATION �..
--
Facility/Owner Name Facility lD9(ifapplicable) ft. ft.
253 PLANT ALLEN ROAD BE MONT 28012 : : ft. -ft. MAR_2 % _?l
Physical Address,City,and Zip,' ft. ft. _.__ ,•. - `
GASTON 2LREMARKS -
County Parcel identification No.(PIN)
BENTONITE SEAL.-75.0 82.0 FEET' `'""'
5b.Latitude and longitude in degree's/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) .22.Certification:
350 11' 15.83 81 0 00' 38.65"
N W ,t.• r -,
03/15/23 .
Signature ofCeitified Well Contractor Date
6.is(are)'the ivell(s): 2SPermanent "or OTemporary
By signing thi.r,fornt,1 hereby cert Jy ilia''he well(was(mere)construcied in accordance with
7.Is this a repair to an existing well: El Yes or mNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards.and ihot a copy
If this is a repair,fill out known well construction information and explain the nantre of the oJYhts record has been provided to the well owner.
repair under 921 remarks section or on the back of this form.
23.Site diagram'or additional well details:
8.'For Geoprobe/DPT of Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1,is needed. Indicate TOTAL NUMBER of wells (atid'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 95.0
ror multiple wells list all depths ifdierent(example-3 a 200'and 2 a 100') Submit this GW4 within 30 days of well completion per the following:
85.0 24a. For All Wells: Original form'to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.} Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If maler level is,above casing,use"+
11.gorehole:diameter: 6.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program, 1635 MSC,Raleigh,NC•27699-1636
12.Well construction method: SONIC
24c:For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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
Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13a.Yield(gpm) Method of test:.
13b.Disinfection-type: Amount:
• Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018