GW1--03380_Well Construction - GW1_20230517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 1l.wATERZONES
Well Contractor Name FROM TO I DESCRIPTION
ft.A - 4121 ft.
rr. D.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased'wells)OR LINER if a t licable)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERL\L
Company Name
0.0 f1. 1 68.0 ft• 8.0 'n SCH 80 PVC
W R0300124 16.INNER CASING OR TUBING eothermal closed-log
2.Well Construction Permit#: TO DIAMETER THICKNESS NATERIAl.
List all applicable ire/1 c•onsiruc000 permits(i.e.U1C,Coumsq State,Variance,etc.) ft. ft. in.
FROM
3.Well Use(check well use): ft. fr. tn.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑IVlunicipal/Public ft. ft. in.
❑Geothermal(pleating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in..
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EIIPLACEMENTMETHOD&AMOUNT
Non-Water Supply Nile]]: 0.0 ft' 680 ft- NEAT PORTLAND CEMENT SLURRY(PUMP)
MMonitoring ❑Recovery ft. ft.
Injection Well: ft. R.
❑Aquifer Recharge ❑GrOLInd\later Remediation
19.SAND/GRAVEL PACK ifa ilicablc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO NATERIAI. Ep1PLACEMENT METHOD
❑Aquifer Test ❑Slonmvater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
FROM' TO DESCRIPTION(color,hardness,soil/rock tv c,grain size,etc.)
0.0 ft. 5.0 ft. GRAVEL
4.Date Well(s)Completed: 03/09/23 Well ID# EX-58 . 5.0 It. 10.0 ft. SILT/ROCK
ia.Well Location; 10.0 ft. 30.0 ft. RED CLAYEY SILT
DUKE ENERGY OF THE CAROLINAS ALLEN STEAM STATION 30.0 ft. S0.0 ft. BROWN SANDY SILT
Facility/Owner Name Facility IDO(ifapplicable) 50.0 ft. 58.0 ft. PWR
253 PLANT ALLEN ROAD BELMONT 28012 58.0 rt• 241.0 ft. ROCK
Physical Address,City,and Zip ft. ft.
GASTON 304337 21."REA7ARKS
County Parcel Identification No.(PIN) OPEN HOLE
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Cield,one lit/long is sufficient) 22.Certification:
529578.61033 N 1399702.32288 W � '' 04/11/23
6.Blare)the well(s): INPernianent or ❑Temporary Signature ofCeriihed Well Contractor Date
By signing this form,1 hereby certify that the u'ell(s)was(mere)constructer/in accordance frith
7. Is this a repair to an existing well: ❑Yes or ONo l.iA NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and ilia/a ca/ry
lfthis is a repair,fill out knomn well con.snvc•tion hJbrination and explain the nature ofdte oflhis record has been provided to the rrel/owner.
repair runlet=2/remarks section or on the back ofrlris Jornr. �.:6�...;�..,'�--`a rt. ��7M•r
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional AAsyy I��o str�4yti4y�u f
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach addiffiallpaes i#nc11�5a .
drilled:
24.SUBVIITTAL INSTRUCTIONS .. � u 1 �'
241.0 {n;o;r�`s,��n : fC.'Ja�'F:i?r0 •,r;:
9."rota/well depth below land surface:
tar nwhiple rre//s hs/a//depth.,if'diJJerem(example-3 tt700'mid 2 n 100') Submit this GW-1 within 30 days of well completion per thc"1•i)Ilowing:
10.Static water level below top of casing: 15.2 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.)//'wrier level is nborr casing,use Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
"
11.Borehole diameter: 16.0/12.0/T0 (in) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/AIR
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: 24t1. For Water Yells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh;NC 27699-161 1
13a.field(gpm) Alethod of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department or Environmental Quality-Division of Water Resources Revised 6-6-2015