GW1--03362_Well Construction - GW1_20230517

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor information:
KENNY SARGENT 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 4226
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased welts OR LINER if a nlicable)
GEOLOGIC EXPLORATION FROM TO DIAM1tETER THICKNESS DIATERIAL
ft. ft. in.
Company Name • -
16.INNER CASING OR TUBING:. eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS: .MATERIAL
List all applicable wel/construction perinits(i.e.t/IC,County,State,Variance,etc.) 0.0 ff 106.0 It- 2.0 in. SCH 40 PVC
3.Vell Use•(cheek well use): ft. fr. in.
176 SCREEN
Water Supply Well: FROM., TO .DIAMETER SLOTSIZE THICKNESS- MATERIAL
❑Agricultural ❑Municipal/Public 106.0 ff 116.0 ft• 2.0 tn• .010 SCH 40 PVC
OGeothermal(Heating/Cooling Supply) bResidential Water Supply(single) it. ft. in.
❑lndilstrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
❑Irri atlon ❑Wells>100,000 GPD FROM - TO MATERIAL EMPLACEMENT METHOD S ANIOUNT
Non-Water Supply Well: .0.0- fit- 98.0 ft• AQUA GUARD SLURRY(PUMP)
OMonitoring ❑Recover' ft. ft.
Injection Well: it. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK if a tlicnble)
❑Aquifer Storage and Recovery. ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT DIETHOD -
❑AquiferTest ❑StonmvaterDrainage 104.0 ft• 118.0 fL 7-35(#2) POUR
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/COoling Return) ❑Other(explain.under#21 Remarks). FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
0.0 ft. 1.0 ft- GRASS/TOPSOIL
4.Date Well(s)Completed: 10/21/22 Well iD# EMP-9D 1.0 it• 13,0 ft. BROWN CLAY
5a.Well Location:- 13.0 ft• 66.0 ft• BROWN SILTY CLAY
DUKE ENERGY OF THE CAROLINAS ALLEN STEAM STATION 66.0 ft• 98.0 it• BROWN SILTY PWR.
Facility/Owner Name Facility ID9(if applicable) 98.0 ft. 104.0 ft. GRAY ROCK
2S3 PLANT ALLEN ROAD BELMONT 28012 104.0 ft• 116.0 ff GRAY.PWR
Physical Address,City,and zip 116.0 ft• 128.0 ft• GRAY ROCK.
GASTON 304337 2L REMARKS
County Parcel identification No.(PIN) BENTONITE SEAL 98.0-104.0 FEET&117.0-128.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
526922.39435 N 1400532.80028 W
04/11/23 .
6.1s(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor �( fat "
Hy signing ibis•form,I hereby certify that the u•e1/(s)was(were)c•onsrrt uGt'_ it 4"ccr;r`lauC•g fCid�l •:-,�
7.Is this a repair to an existing well: 01'es or [5No 15;1 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Slane ,,a<'/#tag a Ai
of this record has been provided to the net/owner. MAY ]
p V
If dris•is a repair,fill not knownu•eN construction iq/ornrnNnn and urpinin the nature of tile tV1H I
2
repair tinder rill rentnrkr.rectiat or an the back n/7lnis jornt.
23.Site diagram or additional well details: 023
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additidPilSl lie}Ltrogstrr"r,"info
1 u ion
construction,only I GW-I is needed. indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional p is,if nbee aYw=„�Lip
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 116.0 (Ct)
For nnu/liple irelh list all depdrs ifd?flerew(example-3Ca 200'and 2a 100') Submit this GW-I within 30 days.of well completion per the following:
7.06 24a. For All Wells: Original form'to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 N1SC,Raleigh,NC 27699-1617
l(water level is abore caring,use'•+"
11.Borehole diameter: 6.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(10C)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC
24c.For Water.Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.). county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form G W-1 North Carolina Department of Environmental,Qualily-Division of Water Resources Revised 6-6-2018