GW1--03375_Well Construction - GW1_20230517

WELL.CONSTRUCTION RECORD(GW-1) Por Internal Use Only:
I.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES i
Well Contractor Name - FROM TO . DESCRIPTION
ft. ft.
A - 4121
fr. ft.
NC Well Contractor Certification Number 15..OUTER CASING(for multi-cased.wells)OR LINER if a licable)
GEOLOGIC EXPLORATION FROM � TO DIANIETER• THICKNESS rIATERIAL-
Company Name
0.0 tt. .156.0 � 'ft. 8.0 in. SCH 80 PVC
_
16.INNER CASING OR.TUBING eothermal closed-loop
2.Well Construction Permit#: VV R03001 24 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.v.111C,County.Slate,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.FROM SCREENTO DIAMETER SLOT SIZE THICKNESS AIATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply). ❑Residential Water Supply(single) ft tt in.
❑Industrial/Ctimmercial OResidential Water.Supply(shared) 18.GROUT
❑lrrt ation ❑Wells.> 100,000 GPD FROM TO ,11ATERIAL EMPLACEMENT METHOD&AMOUNT
Non-WatceSupply Well: 0.0-. ft. 156.0 ft' NEAT PORTIANDCEMENT SLURRY(PUMP)
15Monitoring - ❑Recovery ft. ft. "
Injection Well:"
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediatiori
19.SAND/GRAVEL-PACK(if applicable)
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO - MATERIAL EMPLACEMENT NIETHOD
❑Aquifer Test ❑Stonnwater Drainage tr. ft
❑Experimental Technology .'❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
FROM, TO DESCRIPTION color,harshness,soil/rock type;grain size,etc.)
❑Geothermal(Heating/Cooiing Return) ❑Other(explain under#21 Remarks)..
0.0 . ft• 2S.0 rt:. RED CLAY
4.MIteWell(s)Completed: 03/22/23 Well ID# EX=63. 25.0 ft- 125.0 ft. BROWN SANDY SILTY CLAY
5a.Well Location: 12.5.0 ft- 145.5 ff PWR
DUKE ENERGY OF THE-CAROLINAS ALLEN STEAM STATION 145.5 ft• 246.0 ft: ROCK
Facility/Owner Name Facility ID9(ifapplicable) ft. ft.
253 PLANT ALLEN ROAD 15ELMONT 28012 ft. rt.
Physical Address,City,.and Zip ft. ft.
GASTON 304337 21:REMARKS •"'
County Parcel Identification No.(PIN);
OPEN HOLE
5b.Latitude and longitude in degrees/nliiiutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
525224.54268 �, 1400536.17681 w 04/11/23 .
6.Is(are)the well(s): 091'ermanent or '❑Temporary Signature ofCerhified Well Contractor Date
By signitrg this form,I hereby certify'dat lire well(r)was(here)rronsrr icfe'iri n'cgr aitc•,.Fiq^rt/1',
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01L'.0100 or I5A NCAC 02C..0200 1YeN Carrsrrncijoit YiQarl1}r�lr^ aul rarki cay =
lfihis is a repair,fill our knon•n well construction h formation and explain the nature ofYhe ofrhir record has been provided to the well owner. y
repair under-21 remarks section or an the backofrhir lbrm. MAY 1 7 20�3
23.Site diagram or additional well details:
8.For Geoprobe/DPT-or Closed-Loop Geothermal 1,11616 having the same You may use the back of this page to provid6 additional well construction info t
y tipyla{:p8ses'ttene e"5s3fy3 UG"
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Y6u may also attachr
drilled: 24.SUBIVIITTAL INSTRUCTIONS
9.Total well depth below land surface: 246.0 (ft.)
For intritiple wells list all depths ifdifJcrenl(exannple-3 rr 200•ant!?a,100) Submit this GW-1 within 30 days of Well completion per the following:
16.Static water level beloiv top of casing: 86.3 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
1f wnrer level is above casing,use'• -_ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
16.0/12.0/7.0 24b. For iniection Wells:Copy to DWR, Underground Injection Control (IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699=1636
12:Well construction method: AUGER/AIR
24c.For Water Supplv and Open-Loon 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,']611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Fonn G W-I North Carolina Department of Environmental Qiiality-Division of Water Resources Revised 6-6-2013