GW1-2023-02573_Well Construction - GW1_20230410

WELL CONSTRucrION RECORD For(victual Use ONLY.
This form can be used for single"nurllipk wells
1.Well Contractor information:
I-LIVATERZONES
Zach Thompson PROM TO 11FICRIPtION
WellCotiracwrNantc R. ft.
4478A fit. fL
NC WellComrclorCcn)ftcationNumber 15.OUTER CASING rrdr.intilt[4ikti—WiUslORLINERflf Beabk.
FROM TO mum'TER Rlnct vl€ss AtATEn1AL
SAEDACCO Inc 0 (it 48 fL 2" in, SCH-40 PVC
Computl-Naox lid.,INNER'CASiNG OR'Til61NG +L�,iGerroal cWscdaon
17RO-M To DLl14ETER THI M1EA SIAMME.
2.Well Construction Pei-Knit R. ft, nc
L,srasl app1 ablr k ell permits fir..t=ouniv.:Surm,rlariorwe.Iryerdal err.) tt fit. ire
��l
3.Well[use(eheelcncll use): 17.SCREEN
WaterSuppiy Well: MOM TO 11MME.TFit sr,OTsM T1ttCKNSs I MATrwAt.
[1r ocuitural ONfunicipaliNbliC 48 R. 58 R. 2" in. 010 SCH-40 PVC
®Geothermal(FleadrtgfCooling Supply) ©Residential Water Supply(single) fit' M 'o
®hidustrial/Comtncicial ©Residential Water Supply(shatt:d) I&GROUT'
FROM To NIATERrhL i n1PEACENMNT 111EM0D S Mf01JNT
❑irri ation 0 R. 38 fL Portland Injection
Non-Water Supply WeR.-
rt
❑hlonitodpl; f3Rcm-cry R
Injection Well: f4
l7At}itifcrRccharge 17GrouMvIalcrRerac(Iiation 19:SANDIGRAVEL PACK'fir iitdicab[L)
FROM TO AIATnRIAL HNIP1 ACMIENT�1 r:TNOn
❑Aquifer Storage and)iccofcry' ❑Salinity'Uarricr 43 R, 58 ft. Filter Sand #2
❑AquifcrTest ❑Stem% atcrDrainage
R. fit
❑Experimcnial Technology ❑Snhsikncc Centre(
'20:DRI[.L1NG'IAG(attach additional.shcets if ieecessan•)
13Geodiemtal(ClustdLoop) OTracer cRost T%} DESCRIPriONtmbr,t+rrduc.+wi;'nMk(rx.^ 'uwa�Hcl
❑Cimtherinal(HealingfCooliu2Retutn} 00flier(explain under#21Remads) 0 ft. 58 R, Tan Silty Sand and Saprolite
58 ft. fL Rock
4.Date Well(s)Completed: 3/l/2023 WctIID#PZ23-12
fit. (L C -
5a.Well Locatutn:
Duke Energy fL If. A P f�
Faci)ityoUivncrNamc FacilityMM(ifapplicable) ft, R, L? -t+ V3
253 Plant Allen Rd., Belmont, NC,. 28012 ft., fit - "' '' ' ' r<`'=''"•.J^•ryry r t,n
Pinsicnl Add04
ress,City.and Zip .21.REMIARI:S'
Gaston Bentonite Seal from 38'-43,
C<nutly ParcelldoalificilionNo.(Ph11)
Sb,latitude and i.ongitude in deg yceslminuteslseconds or deeirnwl degrees: 22.Certification:
(lfnell field,ors lab7oug is s,dllcknl}
35.1153 N -81.0051 3/3/2023
ig oturcafecitiGcMW Cmutactar Daic
6.Is(are)the well(s): Meer umnent or ❑Temporary 1h•signb,b lbir form,1 irerebr rerfifr rhalr rl,e lrel'If5)(SLY(lrrrL)conrrnrcred i,r a[Y'ordn'nve
with I'M AVOW 02C,0100 or 1 Sit NC;IC 02C,02MI Well Consirrrcdal Standards anal dwr a
7.Lti this a repair to an existing well: Mo-s or MND C[�ry of rlllf r,'CDrrl bras Ih'rn pt,Yr'ifl,'d a.11rr urll mr,u+r,
iftbfsis a repair,fill exit kt7r nvl uefl rnrutnrrtlnn luforna;rlar and eeplabt rile wrare of nc0
repair umlcr A21 retaarkv archon or on the bask ofllri,fornc 23.Site diagram or additional[sell detaite:
You may use the back of this page to provide additionat welt site details or%sell
8.Nutuber of%vells consimeted: 1 cousituction details. You nlav also attach additional pages if necessary.
For)a.Otllle bAvfiom or om-outer supple n'elfs ONLY w1rh riot same wovstrurtiorr,yin%Can
zebu,&one form. SUBMITTAL iNSTUCTiONS
9.Total well depth below land surface:. 58 ((y,) 24a. Ear All Wells: Suhtrdt this form%,H(hin 30 days of completion of wall
Formahlplehellslistrtflrieprhsifdifr'errru(craapfe-3@?00'aiul2@IM) constntction to thefoitaning:
I0.Static water level below top of casing: ((y,) Division of Water Resources,Information Prucessing Unit,
1f,valer level Is above ewfog,ace"+" I617 Mail Service Center,Raleigh,NC 27699-1617
H.Borehole diameter.8" (in) 24b.Fur iItiecflan WglhONLY: in addition to sending the form to the address in
24aabove. also subruit a copy of this funs within 30 days of completion of%veil
12.lirell coustructiou method:HSA construction to the following:
(Le.--Wr.rciary,cables direct ptlSIL etc:}
Division of Water Resources,Underground[ttjectlon Control Program,
FOR WATER SUPPLY MILLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1344 Weld(gpm) Method of test: 24c.For Watcr Suit&ak f&ctiun'Wclls:
Also submit one copy of this form %%ithin 30 days of completion of
13b.Disinfection Iypc. Amount, well construction to the county Stealth department of the count)'where
constructed.
Fami MY-I North Carolina Depdruncin of Enviromtktu and Natural Resources-Division of WaterEtmou Revised August 2013