GW1-2023-02571_Well Construction - GW1_20230410

i
WELL CONSTRUCTION RECORD For lmvnnl Use ONLY:
This form can lv used rw single or inadtipk iwils
1.Well Contractor Information:
IIMATER.ZONES
Zach Thompson F140NI To OMICR1PiION
WdlCorricrciorName
r1. rt.
4478A
NC Well CammctorCerflib ation Numticr '15,OUTER CASING(fbrfuulR-caved WillsfOR LINER"Ia flcable)
MOM TO Drx mETBR TflICt{NE55 AIATERTAL
SAHDACCO Inc 0 (L 62 (L 2" in. I SCH-40 PVC
Canv:uty Nauw MANNER CASING OR:To111MG ihLrin d clar 400
FRONT TO DIA:'1IETE6 WERNE R. MATERML
2.Wc1l Construction Permit
1r51 all apq ikablr.tmllpenreits(i-r..County,Siva!,,variarwe,1rYer r4 eir..)
tt. fL in.
3,Well Use(chute well use): 17:SCREEN
- - - FROM TO DrAMETER srt)Ts1". Tnr( INM MATFMA1.
`4aterSulgdy Well-
CiAgricultutal Mfunicipalftblic 62 ft. 72 R. 2" in. .010 SCH-40 PVC
QGeotkimal(Iieati 1Cooling Supply) ®Residential Witer Su fL fL i1►.
D&' e. l P PPiS'(single)
�hidustriaUCoRu►tercial QResidential Water Supply(shared) t8:GROUT
_ -,-1 TU ;•L�TI?dtIAL L+\[PLACEF1tLVT\tEntOn RA\fOU�iT
❑1ni alion 0 f4 52 fL Portland Injection
Non-Water Supply Well: fL fL
IDNlonitoring QRccocct}'
Injection`4VelL• t4 rL
0Aquifer Recharge QGroundvoct Rco cdiation tv:SAND1GRAVELVACK(ir a r rliL:abrt-)-:
FROM 'M NIXT r41. RN1Nt.a(:T:vn:NTHt:r11On
QArjrrifc[Storage and Jtecavcty' QSalinin•l3amcr 57 R. 72 ft. Filter Sand #2
QAgaifcrTest ll t©mmNatcrGriinagc
ft. ft.
QEgleiimcnt it Technology QSilbsidcncc C01001
Sn.-DRILLING LOG(apacd additioaatshcels if ncccssanl
OGeothenual(Closed Loop) OTracer FRONT To DESCRTPrtO\(enbr,hartlnecr s"IA'nrcktr .- n.vc.nr.T
17GeatLellnal(Heating/CuolingRetum) Miter(e plain under 921Retnalhs) a fL 72 fL Tan Silty Sand and Saprolite
72 fL fL Rock'
4.Date NVel,10)Completed: 2/23/23 ` etllD#PZ23-07
$a.111M Locution: fL fL
Duke Energy f4 fL ,
Facilityl(hvnerNarr_re Facr74M(ifapplk:ablc) ft. it. iry_.`'"ryji l
253 Plant Allen Rd., Belmont, NC, 28012 . f4 fL ,;'t�^ `''-J rl%
70 7,
Physical Address.City.and Zip ;:2 L RENIARKS
Gaston Bentonite Seal from 521-571
Correll' I}arcc]1tknliriC111gn No (PIN)
Sh.Latitude and Longitude in degrees/minutes/secouds or decimal degr'ces; 22.Certification:
(ituoll 1101d,011C I;iblung is srdllCLmt)
35.1142 N -81.0042 W � 2/28/2023
recuturc ofCcit[fred 1Vc CoIW actor Dale
6.Is(are)the well(s): %Permanent or DTemporlt}
1h•signing this form,1 hrrebr certifs•rhru thr nd!{s'1 tsgs-(tsrre)cwrirrrucrerl irr rrcrorrlancr
o'irb 15A NCAC 02C A1tT'7 or 15A,YCAC 02C.0200 Weil Constracrion Staryfards trnd ibat er
7.Ls this a repair to an existing well: ElVes or MNo CrytroJNiir mcnnlltrsburn pt»witrd to the.cull mv,p'r,
dithis is'o repetlr,fill taitAncona wellcmwn(cdea ltrforrnarlartrade.tplobr rile nvrare ofrlic
mpairuader#21 rrinarksserihm orrm die back-ofthis fornL 23.Site diagrain or additional well detaiLi:
You may use die back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You pray also attach additional panes if necessary.
For tnakVe Injewimr or ars'r-nxrter supply'wells ONLY.idd1 dm same constraerlar,yea Carl
saNrit oar forn. SUIDNiLTTAL INSTUCTiONS
9.Total well depth below land surface. 72 (ip,) 24a. Far All Wells: Submit tliis farm within 30 days of completion of well
For nrahiple it•ells list all depths lfd&%rtnr(ertapple-3G_D20(r and 2@ 100) construction to the following:
10.Static water level below top of cmiuW. (II,) Division of Water Resources,Information Processing[unit,
11 uwter level Is above vasing,tee"+" 1617 Mail Service 6awr,Raleigh,NC 27699-1617
It.borehole diameter.8" (in.) 24b.Fnr lniccllon Welly ONLY: in addition to.sendinR ft form to the address in
24a above,also submit a copy of this form within 30 days of completion of well
12.Well toustmetiou method:HSA consimctieut to the following:
(i-c.auger.rotary,cables dime puck efc:}
Division of Water Resources,Urtderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13;L Yield(arm) Method of test• 24c.For Water SupV113r Inj_cetion Wclls:
Also submit one copy of this fond within 30 days ofcompletionof
13b.Uisinfcetiun hpe Amount: tvctl construction to the county health
lth dgmriment of(tie crnmty where
constructed.
Forni GW-i Noah Carolina Ilcpcmmbmr of Enviroam ni and Nnurral Rcsources-Division of Water Ri-Mtrces Revised August 1013