GW1-2023-02572_Well Construction - GW1_20230410

WELL CONSTRucriON RECORD For tsicrnnl Usc ONLY.
This Conn can W used Car single or tnoltip}c 11•ctls
I.Well.ContractorInformation:
'14.WATER"LONJS'.
Zach Thompson FROM TO 0WRIPTION
{{'01CorvaaaorNamc
4478A
rt, rL
NC Well ConuaclorCertiflcation Nawhcr tS.OUTER CASING Mr—kuha '1140RLN (if ' abk
SFROM 114ETR T � MATERIAL
SAEDACCO Inc 0 tL 1 58 fL 2" in. I SCH-40 PVC
(:nnprut)'Nanae I6.INNER CASING OR. RING`geoihermal ciascd4on r,"'
FROM TO DULNEETER TIIICK�P.54 M.4TETIL4L '
2.Well Construction Permit Rl R. ft,
MrollaJplicable rcellpeamils(U.County.31ar.'c,lrariauce,1rye:dC4 ei.)
Ft. (L
3,Wdl use(chcchwdl use): 17:S('RUN
TnICN TV DLANIMIt y, NNSS MATRRIAI,
Water Supply Well.- FROMSt'"$Il
OAgricultulal O1 funicipal ttbllc 58 ft. 68 R. 2" ik .010 SCH-40 PVC
OGeothetmal(HeatinglCoaliog Supply) ©Residential Water Supply(single) fL fL isa,
®IndustriaUComatcrcial ®Residential Water Supply(slated) 18.-GROUT.
FROM TO MAMMAL I ENIPLtCEFILNT 11EMOD,s A,\101J Tr
Olin ation 0 ft, 48 fL. Portland Injection
Non-Water Supply Welt:
Immonitodng t7Rccm'cry ft, ft.
Injection Nell: ft, fL
l7Aquifcr Rcct}arnc CJGtoundl,ntcr Rcnicdimion 4%SANDIGR WEL PACK(if a a ilicabre)
T53:
OM TO \IATNRrm. rt11P1'%Cn1r.NTMr:TROh
IDAgnifcr Storagc and ltccarcry• ❑Salinity Harrier R. 68 ft, Filter Sand #2
❑Aqui(crTest ❑Stormwatcrarttrragc ft. I ft•
❑Experimental TcLmotogy ❑Stthsidcncc Conlral
'20;'DRILLIi\G'LOG(attach additianntstrccts it ncccsmn•1
OGeothemtal(Closed Loop) OTracer FROl1 TO DFSCRrFtIONrc»bnn�atittte�t wn'rkkly 1t w adt.}
❑Geodiennal(Ffeating'Cooling Retum) Oother(explain under 921 Rematfs) 0 fL 68 fL Tan Silty Sand and Saprolite
68 ft, fL Rock
4.Date Welt(s)Completed: 2/28/23 ` dl[D#PZ23-09
$a,Well Location: fL ft
a _
Duke Energy ft, fL AFpk
FacilitpOwnerName Facility IDT(ifapplimble) ft ft
253 Plant Allen Rd., Belmont, RC, 28012 ft fL ur.•,,;.,;,.n l ,,.- ^ a r
Physkal Address City-and Zip 12L REMARKS:
Gaston Bentonite Seal from 48'-53'
Coatd}' Nrcel I(krilinC;pit)uNo.(PIN)
fib.f atitudc and Longitude in dcgn'cdminutcslscCn'nds or decimal degrees: 22.Certification:
(if ucll field,oats IalAloug is srdlickrd)
35.1965 N -81.0145 W eu' 2/28/2023
I;Intuus of Ccet[ficd{Yc t Canitaetar Dam
6.Is(ate.)the well(s): EPermanent or OTemporary th•signing rhir farm,I herebY cerrifc rbar A r nrll(.0 w=fnr),!J corninrcied irr mvorT1m ce
with!SA NCMC 02C,01M or 1 SA KCAC 02C.020D Well Coatstracriat Swrklards and retest a
7.Istf6a repair toaneu4tingwell.- r7Yev or ENn r!�rolrltleracon}Jhosheenpmvirta'drnrhntndlanrater.
if rbls is a repair,fall ow krotra Weil caiwntedoa l,rjormarion mul e.lplabt the narare of the
repairrarder P-I reanarkv.irc-tiva or rm rhL bcrl•of lhh form. 23.Site diagrain or additio ual well details:
you may use the bact,of Utis page to ptovide additional well site details or well
ti.Number of wells constructed: 1 constrction details. You may also attach additional paLvs if necessary.
For ntatlrlple laJerrlon or orm-nmer supXv welb ONLY with die strma consrrucrioar,ycut can
subntironeforrn. SETBRf[TTA .INS'f T .TI©NC
9.Total well depth befall land surfaces 68 24a, Far Alt Welts: Submit Ilus form within 30 days of completion of well
Forittakiple wells list all4lepOslfdlfirenr(cxmop(e_te•e00•aaul2@1M) eonSlnlctionto the foltoning;
10.Static Hater level below top of casing: A) Division of Water Resources,taformatiam Processing Unit,
If naaue level is above easfiAg,am"+" 1617 Mail Set-vice Center,RAIdgh,NC 27699-1617
11,Borehole diameter.8" (fn,) tab.Fnr Rtftctlnn Welh ONLY: In addition to sending 1W foml to ilia address in
24a above,also submit a copy of titre foam within 30 days of completion of wall
12.Well construction method:HSA construction to the following:
(Lc.augcr..rnwiy,cable direct push ctc.)
Division of Water Resources,Underground Tnjection Control ProgrAm,
FOR WATER SUPPLY WELLS ONLY: I636 Mail Service Center,Raleigh,NC 27699-1636
13:t.Yield(gym) Method of test: 24c.For Water Supply&InjcctianlWelt,
Also submit one copy of this form within 30 days of completion of
13h.Disinfection In-pe: Amount: hell construction to the county€rcalth depanmcnt of the county n•herc
constnutcd_
Form GI{'-t Rosh Catalina D pdnmoar of Em'ironmcm and Narnral Resources-Divi:lon of ti{'alcr Rmou Revised August 2013