GW1--03022_Well Construction - GW1_20230306

WELL CONSTRUC'CION'RECORD For tnt mnIUsc:-MY:
This fanncan be used for single or tnnldole wells'
1.Well Contractor Information:
14.%VATER ZONES
Zach Thompson FROM TO DFSCRtF"ON
41'e1lConiraclorllanrg
4478-A
NC Well CommcrorCettif tionNituber 15.OUTER CASING treemuhl-6kd`deHslORLR able EflTALFROI TO PEOVETER TDiCNNi:S5
SAEDACCO Inc 0 fL 1 33 ft. 2" in., I SCH-40 PVC
Ctmfpmty Name 16.INNER CASING OR TUBING' •eoibermal elased-too
FROM I TO I DLOIETEn I THICaLLNCSS I f1A7ERIAL
2.Well Construction Permit 9: R• ft. tlL
4W all ajyiSrahle VWhprnWill(ir.Caunry.:Stu:r.,T/driat>re.Ir}re:d04 err.)
ft. tt. 4
3.Wcll Use(chCCIC%well use)-. 17.SCREEN
Water Supply Well:
DtAttEThR srATS1", TNTCUNr_S 51ATRRIAr.
riAgicultural ON6funicipaVpublic 33 R. 43' ft. 2" IR• 010 SCH-40- PVC
®Geothermal(Iieatingilaoling Supply) ®Residential Water Supply(single) ft. fr. ire.
©hidrustrial)Contmcraial l7Residcudal Water Suppbs(shared) U.-GROUT
Ftrorr To NLA'reRfAL earncAca:,rteNr\1EfifOD 8 AMOUNT
❑lrri ation 0 ft. 28 fL Portland Injection
NonrWater Supply Weil:
ft. ft.
MMonitoring []Recovery
-Injection Well: tL to.
MARuiferRccharge (]Grout dwalcritcmcdiation °is SAND)GRAVEL PACK(if tl16ibte)
FROM TO � MATERIAL R\1Pr.ACFNrENTNFTHOn
AAijnifcrStaraacairdRccatcip ❑Salini(yHaTIICr 31 R. 43 ft. Filter Sand #2
0AquifcrTest M.Stomr atcrDroinagc
ft. ft.
DExperimcntal Twirnotogy ❑Subsidcucc Conliul 20.D1LlL@ 9NC'1 OCfnnacd adt[ltional sticefs It necessan 1
❑Gewhertmd(Closed Loop) ❑Tracer 'MONT I To DESCR@T1ON aokr.harhevo.uAlrick ope,moin we.c/G)
❑Geothermal(lfeatinglCoolIug Retum} ❑other(Mlain under 921 Retuarl s) 0 ' iL 43 ft. Brown Sand
2-15-2023 CLF=23-407
4.Date Well(A)Compl¢ted; tiirelllD>F ft..
S L tL MAR i)
Duke Energy fL ft.
FaciilityMu-norName FacilitytDkGfapplicablc) R. ff. "�•"' '" r r; ^::;3 !_fte2i
8320 NC-150, Sherrills Ford, NC, 28673
Physical Address.City.and Zip 21.REM1tARfCS'
Catawba Bentonite seal from 28-31'
Caeiuly }'areC]IrlrmliCr61Uen No.(PLN)
5b,i,:ttitude and I ringittede in de*reeslminutcs1sec0nds or decimal d(grees: 22.Certification
(it%,cu ricra,o,.:)aL7oug is xielrieiced)
35.6183 I1 80.9745 W ,.,�j � 2/16/2023
tgmturc ofCcitilicd We Contrxtar _ Uare
G,Is(are)the%vell(s): xWernanent or ❑Tempor•ar}
BY,rlgning thir.futm,1 herrb)•crrrijy char rlu vrll(s)t+Yrr(wr�vJ carsrrucrrd in accarrlmicr
with 15A NCAC 02C,0100 or 15A Ncetc OZC A200 Well Cvnsrract(atr Srarplards tread that a -
7.Is this a repair to an c%dsting well: l7YLs or Mo. roper o0iif record hhs•bent prnrided melt uril neater,
ifibis is a repolr,fill oarkvouvj well corwnrciloa brformarlontree!raplabi the mrare ofdie
repair under#21 remarkssrcrian aron the back-ofthirform. 23.Site diagram or additional well detaiN:
You may use the bacl;of this page to provide additional well site details or%sell
8.'Numberof wells constructed• 1 construction delaiNs. You may aLso attach additioual pages if nevessary.
For taailrlple f4evrlvn or am-nbrrr sappily ivcips ONLY.n•irh rha.satne constrwilon,you cda
.submftone farm. SUBMITTAL iNSTUCTiONS
9.Total well depth belaw land surface: 43 ((}t,) 2aa. For;All Wellr:. Submit this farm within 30 days of eompterion of%cell
Fornrrtlrlpiciv ells list all tfeprhs(tdiJ)•err)t(exciaiplc-J0-:OA'aru12911Hi) constructionto(hp fofto%ving:
10.Stacie%valet toter below top of casing: 19.4 A) Di%•isian of Water Rcrource_s information prneessin-Unit,
If nnter leyd is above eaebt?,are"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.8.25" On.) tab.Tnr lnfMa5►n Welly ONLY: in addition to.sending the form to Are address in
246 above.also submit a-copy of this form within SO days of completion of well .
12,Well construction method:HSA constmctiou to the following.
(Le.auger.ro(a[}•.cable direct push etc:)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELIS'ONLYi 1636 r6il Sereice'Center,Raleigh,NC.27690-1636
13a.Yield(final ltictlrvel of test 24c.For Water.Sue .4r injection Wc11s:
Also subritit one copy of this fort within 30 daysofcornpletion of*
13h.DL%infection type: Amount- well consiniction to the county hu,illh department of the county-when;
cortstnactcd.
Fenn G W-t N4onh Carolina Depaamicnt of Em•ironnical and Warural Resources-Division of Walcr Reso.— Revised>;ugaat y(►13