GW1-2023-02575_Well Construction - GW1_20230410

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WELL CONSTRUC'CYON RECORD Far tarsal Use ONLY.
This form can ho used for single or muddpk wells
1.Well Contractor lttformation:
4.,%VATERLONFS
Zach Thompson FROM 7o OFSCrnPTION
Well ConitactorMum ft, ft.
4478A ft. fL
NC Wall CararactorecitJReation Number 15.OUTER_CASING(r4i inuGi-¢aatd,cefls)OR LINER(if a' ncabkl,-
FRONT I To MAATETEtt THICKNESS SfAMMI,
SAEDACCO Inc 0 (6 1 51 fL 2" in. SCH-40 PVC
ComF;nty Nanm I6.INNER CASING OR:T1J81NG: eai6crmat dared-loo .
FROM 1110 DLLAEFTEn TnrCKNESS AIATERUL
2.Well Construction Permit R: R. tt. 6L
List.01ln},yXMhle rcellpetm(ta(fir.Caunn',Stun.,Variance,lrya:dM err.)
3.Well Use(cluickwell usel: t7:5CRi E N
-
water Supply well:- -- -- -- -- --- -_ - FROM TO O M IrMt SLOTSM, I TIMCHMS I !1rATRRIAI,
OAgricultntal OMunicipal/Nblic 51 ft. 61 ft, 2" in. .ono SCH-40 PVC
®Geothermal(2ieatt Coolie. S tyl ®Residential Water Su fL R.
�' g nPP PPI}'(single)
Olndustrial/Conmtcmial ORcsidendal Water Supply(shared) IN.'GROUT
FROM TO J:fATEREAL EMPLILCEMENT MEMOD S AMOCW,
Oirri ration 0 ft. 41 fL Portland Injection
Nan-water•Supply Well:
Monitoring IRccoycty R. ft.
Irtjecllon Welt: ft, tt.
(]Aquifer itcchargre Moundwhtcr Rerucdimion M SAND1GttAVEL PACK(it a t licabreY
F14ONT 'M MAURM. R�IPI-ACr:MENTMEt'n0n
C]rlgnifcr Storage and RRarcty O5alinityl3ariict 46 R. 61 It. Filter Sand #2
❑Aquifer7e5t 13Stommatcr Drtiwigl:
ft. tt,
[3Experirncnial Technology ASubsidcucc Control
'lo:DRILLING LOG'(allach additional sheets il'necessary)
❑Geolitenn d.(Closed Loop) ❑Tracer FRONT TO DESCRIPTION tubr.hanrncn tutt'mckty , 'fi*e.et&1
OGeothetmal(FleatingLCooling Retuinj ❑Outer•(explaiti under 921 Retuades) � 0 ft. 61 fL Tan Silty Sand and Saprolite
61 ft, fL Rock
4.Date Welt(s)Completed: 2/22/23 Wd1[D#PZ23-03
f[, fL
54,Well Locatbm: ft It.
Duke Energy ft. fl 11 UI r
Facflhy,'Ou•ncrNatuc Facility IDg(ifapplicable) ft. ft. 023
253 Plant Allen Rd., Belmont,, NC,, 28012 It, 1
Physical Address.City_and zip -.2 t:REntAItKS �.
Gaston Bentonite Seal from 41'-461
Coauly Parcel ldestlif[cltion No,(PIN)
Sb.Latitude and l ringitnde in dcgrccslminutcslsceonds or decimal dcgt•ces: ,Certification:
(it%reli field,otsu;lat1ong is sidlickul)
35.1143 N -81.0046 W 2/28/2023
57gnriurc ofCertificd Well Cantrtetor Date
6.Is(tire)the well(s)t MPermanent or- I7Temporary
♦h•signing tlrir fens,1lrrreLr•certify tins rltr u•rl!{sl Kars(wrnrJ cvrarrructed In ecronlaircr
uirh 7fil NCr1C 9oC Aliv3 or 15+t NC.4C OeC.�20(7{li•Il Cusstrrtalon'Srcuyfarcls<rnd rlrrrra
7.I6-thinarepairtaanesistingwell: l7Vey or ®No ccltrojth6rrrcorTlhushrenJrmridtdraterha!leer,✓✓,
if sins&a reprilr,fill cxtt.hiviiar nrl1 c�a�utnrctfoa lnjorrrurrlat oral rtplalr sirs tutrtue ojtlm
repair raider&31 rmnarks•srctina or at the hrtek of this form 23.Site diagram or additional well details:
You may use the back of U(is page to provide,additional well site details or tsell
8.Number of wells constructed: 1 coustmetion delaits. You ntay also auach addilicnral pages if necessary.
For nmkiple lt*rlvn ar arm-n-eirer supply n'ells ONLY rrltli sire 4Tme cOHMF144 .ym cart
salrmlt one fors.✓. S IUNI TTA .INST T .7 IONS
9.Total well depth below land surface: 61 ((1,) 24a. For'All Wells: Submit this farm within 30 days of compterion of well
For rnnhlplttrvelirlisralld'cpAisffdlferent(exaenP?e•-@20P'aW2@r1M) constntetiontothc.follonina:
10.Static water level below top of casing; (ft.) Division of Water Resources,Information Processing Unit,
1f plater level b,above cusiotg,trse"+" 1617 blail Service,(cater,Ralcig h.NC 27699-I617
11.Borehole diameter.8" (in.) tab.Tnr Infection MAN ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this feint within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.a,ttgee rotary,cable.direct pasli.ere:)
Division of NVatcr Resources,Underground Injection Control Program,
1636 Mail Sen9ce'Ceruer,Raiei h NC 27699-1636
FORWrlTERSGPPLY�VELLS@NLY:' I 6 ,y
13a Vicki(upnt) 4lcthal of test: ?lc.For{Yates Sotiply Ac tdmtionl Wells:
Also submit one copy of this for»i within 30 days of completion of
13h.Disinfietiun t•pM Amount: %yell construction to the county health department of the county where
constructed.
Farm MY-I Noah Carolina Depanst rm of Enviroankru and Natural Resources-Diyi;Ion of Water Rp_soix es Rcrtscd August 2013