GW1-2023-02580_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD '
' For[tgcntnl Use ONLY:
This form can be used for single or mtfldpk%•ells
1.Well Contrictor Information:
1J:WATER ZONES
Zach Thompson FROM TO 11MCRIMON
W01 Cor4tactvrNamc R: ft. I 1
4478A f4 fL
NC WdI CamntctorCcnification Nwnbcr 15.OUTER CASING Ube mail-i*d-, cns)`OR LINER(If ii' "eablel
FROM -M I DG4viumit THICKNESS MATERIAL
SAEDACCO Inc 0 (L 1 60 (4 2" ill. SCH-40 PVC
Cangway Name M INNER CASING OR. MING' —Atermal cluscd-loos ),
FROhr- TO DIAMETER TtRCKNESS \IATERLIL
2.Welt Construction Permit#: R. ft. tl4
1 ur u1117Mlicalrle Mr11 permils fr_r..CounrV-Saa.'r,Mardau e,lfferoEn eir..) ®�
r4 ft. is
3.Wclt[ise(ek0crYell ase): 17 SCREEN -Water Supply Weth FRONT To WAMETER SL,OTSIZ.E T}itCKNrSS NTATPRtAt,
OAgRCUlnual _ O.Municipalftb)lic 60 ft. 70 M 2" ira 1 .010 SCti-40 PVC
®Geothermal(HeadngllCooling Supply) ®Residential Water Supply(single) 7L IL
©lndustrial(Couuttcrcial ®Residential Water Supply(sbared) IS.-- TO NL.TER6tL E\[P[ACE\ILVT 1fEn10D S hh1011�Tr
Elk-rigation 0 ft. 51 fL Portland Injection
Non-Water Supply Well:
n, rt.
Mmonitodpg i-)Rwovciy
Injection Well: ra rl.
0AquMcrRccb:irge ®Groundt`atcrknwdialion "t9:'SANDIGRAVEL PACK(if oalicabte)'.
FROM TO ArATQRr4i, R�1Pt.M1C}76r\T HFTnOn
QAquilerStoragc and Rccoss¢ C]811inity131rdcr 55 ft, 70 ft. Filter Sand #2
ElAquifcr Tcst 17Stomtnatcr Drlinige
ft. fL
ElExp imcnial Tcchnology I7S05idcncc Control
'20:DRILLINC'LOG(alladr addltionailshecli if irecessnn}
DGeotltennul(Closed.Loop} ❑Tracer FRONT To DESCRIPTION mbnlrardnc+t.srdi'nkkh ; n*e del
Meadtennal.(Headne/Coolin Return) OOther(ecplaitt under 921Retnatls) 0 ft. 70 fL Tan Silty Sand and Saprolite
70 fL ft, Rock
4.Date Wclt(s)Completed: 3/15/2023 ti ctliD#PZ23-ll
ft. fL
52.Well Location: f (L
Duke Energy t4 fl. A ra rj
Facfl1k,0m-WrName Fict7ily 1Dp(ifapplicable) n, ft.
253 Plant Allen Rd., Belmont,, NC, 28012
Ph)-sieal Address.City-and Zip a21-,REMARKS --- _
Gaston Bentonite Seal from 511-55,
L'ctrrnl)' Nrcel 1Jcolifienuon No,(MV) -
fib,Latitude and I lingittldo in dcgreerdminutaAcctinds or decimal degrees 32.Cettifieafirm:
(if belt field,pore 101ong is srtnieierd)
35.1970 N -81.0101 W a /fL6�lL 3/18/2023
agmtureafCcitifxdt4'c Conttxtar Dale
6.Is(are)the EPermanent or E emporaty
IN signing whir form,1 irerebY certify rhar the wellrsl way fmrrel ce mrfnrcrerl der fiveorrhmce
with 15rt NCAC 02C,0100 or 1 SA MAC 02C,0200 11ell Consimcrlort Srandards and dwy a
7.pis this a repair to an eristhigwell: or ®No COPY O,fthif FeCOrdha.VbeCrr prm'i(A'd unpin ut:l1 coulee,
if rhos b a rcprTin fall aatkrriuvi%•ell o m-mrralon brforrmfion and e.splaha the rrarore of the
repairunder#21 rer»arkssrefimr ar an flee beak of th6 fornr. 23.Site diatgram or additional hell details:
You Ma)'use die baclt of this page to provide additional trell site details or well
S.Number of wells constructed: 1 consltuction details. You lilac'also attach additional pa)vs if nevessaty.
For mahlpde lrrfdcrlon or ant-nnrer nippfi wells ONLY.Trfrh the wine constrarctimr,gear can
sa&nrif anc Jame. .S litllIITTA .f NST T .7YONS
9.Total well depth below land surface: 70 (ft.) 24ar. Fdr All Wells: Submit dris form within 30 days of completion of well
For marklplorcells list afldeprhslfdlflirceulexamplc-3@209'arul2@ldArl) consinreti4n to,lhefolloning-,
10.Static eater level helow tap of casing: (ft.) Dh-hiun of Water Resources,Informatian Processing Unit,
11 Tvdier In el.is above cusing,ase"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.$" (in.) tab.Fnr lnlecflan`Vctly ONLY: in addition to.sending the forut to the address in
24a above, also submit a copy of this fann within 30 days of completion of well
12.Well construction method: HSA construction to ilte following:
(i.e.auger-rotary,cable direct push etc.)
Division of Water Resources,Underground Injection Control Program,
FORWATER SUPPLY WELLS ONLY: 1636 Alai[Service Ce'nler.Raleigh,NC 27699-1636
13a.V icld(gpm) Method of test: 24c.For Water Sanp-1&injection[Wells:
Also submit anc copy of this fdnli Within-10 days of completion of
13h.DisinfLetian Ape: Amount: well consinicaan to the cotmry Ite,lllh departm.-ni of the counh-tviterc
constructed.
Forrn GW-t Noah Carollers Depanawni of Emironnxm and Nanual Resources-Division of Water Rti Su t tm Revised Ai{g M Yo13
i