GW1--03379_Well Construction - GW1_20230517

WELL-CONSTRUCTION RECORD(GW-1) For Internal.Use Only:
1.Well Contractor information: p
NICHOLAS HAYES 14.WATER ZONES "' 6
Well Contractor Name FROM TO DESCRIPTION
A - 4121
NC Well Contractor Certification Number _ 15.OUTER CASING for multi-cased wells OR LINER.if a t tlicable)
GEOLOGIC EXPLORATION FROM TO DIAMETER' THICKNESS MATERIAL
0.0 ft. .95.0 ft. 1 8.0 in. SCH 80 PVC
Company Name _
W R03001 24 16.INNER CASING OR TUBING(geothermal closed-loop)
Z.WcII COHStrUCtinn PCrmit#: FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable yell construction permits(i.e.U1C,County,Stoic,Variance,elc) ft. ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN. _'
FROM TO DIAMETER SLOTSIZE I THICKNESS. I MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
OGeothermal(Heating/Cooling Supply) - ❑Residential Water Supply(single) ft: it. in.
❑Ind ustrial/Commercial " ❑Residential Water Supply(shared) 13.GROUT
❑irrigation' ❑Wells> 100,000 GPD FROM To MATERIAL EMPLACEMENTMETHODC AMOUNT
Non-Water Supply Well: - 0.0 ft. 95.0 ft! NEAT PORTLAND CEMENT SLURRY(PUMP)
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. for.
❑Agu.ifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifsli licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormtvater Drainage for. tr.
❑Experimental Technology OSubsidence Control tt. for.
❑Geothermal(Closed.Loop) ❑Tracer .20.DRILLING LOG attach additional slieets if necessar
FROM TO DESCRIPTION color,hardness,soil/rock type, rain size,etc.)
OGeothermal(HeatingJCooling Return) ❑Other(explain Linder#21 Remarks)
J. 0:0 for 25.0 tr HARD BROWN SILT/ROCK
01/23/23 EX-'59
4.Date Well(s)Completed: Well ID# 25.0 ft- 40.0 ft- BROWN SILTY SAND
ia.Well Location: ,40.0 fl• 85.0 ft' BROWN SILTY CLAY
DUKE ENERGY OF THE CAROLINAS ALLEN STEAM STATION 85.0 ft- 241.0 ft- . ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
253 PLANT ALLEN ROAD BELMONT 28012
Physical Address,City,and Zip q ft. ft.
GASTON -304337 21:REMARKS
County Parcel Identification No.(PIN) OPEN HOLE
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 21 Certification:
529578.61033 N 1399702.32288 W ;� 04/11/23
6.is(are)thewell(s): (EPernlanent or ❑Temporary Signature ofCertifred Well Contractor Date
By signing[Iris form,1 hereby certify that the well(s)n•as(trere)constructed in accordance frith
7.1s this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0/00 or 15A NCAC 02C.020 Well Construction Stantlar-ds and that a copy
1/'this is a repair,fill outknown fretl construction information and explain the nature of due ofibis record has been provided to due ire/1 owner.
repair under?2/remarks section or on the back oJ7his Jbrnr. _
23.Site diagram or additional well details:
8.For Ceoprobe/DP'1 or Closed-Loop Ccothertnal Wells having the same You may use the back of this page to provide additional 1ve19 cclrlSlrt�ttonrfnk>k v .>
construction,only l GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional paw s i ecessarv.
drilled: 24.SUBMITTAL INSTRUCTIONS
A '1 7 2023
241.0
9.Total well depth below land surface: (ft.) 1 punt, g,;,,,3 Ur4
For muhiple irel/r list all depths frtifferew(example-3@200'and 2@100) Submit this GW-I within 30 days of well completion per t41�`lb 01%"i ll,
0"3 ru
16.77 24a. For All Wells: Original form to Division of Water Resources (DWR),
j'u Static water re ca.below top of casing: Ift•) Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
/Jlrntcr level is shore casing,use"+" - � - � � I '
11.Borehole
16.0/110/7.0: 24b. For injection Wells: Copy to DWR, Underground Injection Control(IUC)
diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/AIR
24c.Tor.Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotmy,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
Perinrt Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpnl) Method of test:
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Qualify-Division of Water Resources Revised 6-6-2013