GW1--03402_Well Construction - GW1_20230517

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft, ft.
A - 4121
rt. rr.
NC Well Contractor Certification Number 15.OUTER CASING ffar multi-cased wells OR LINER(if a licable)
GEOLOGIC EXPLORATION FROM f0 DIAMETER TIIICIGN ESS MATERIAL
ft. in. '
Company Name
W R0300124 16.INNER CASING OR TUBING( eothermal closed-loon)
2.Well Construction Per-rnit#: FROM TO DLIMETER THICKNESS MATERIAL.
List all applicable irell construction permits(i.e.UIC,County,Stare,Variance,etct) 0,0 f`' 83.0 ft. 6.0 in. SCH 80 PVC
3.Well Use(check well use): tt. It. in,
Water Supply Well: 17.SCREEN
FROM TO SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 83.0 ft- 118.0 ft- 6.0 in- .010 SCH 80 SS
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft• f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
❑Irrigation ❑Wei Is> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOIJNT
Non-Water Supply Well: 0.0 ft- 73.0 ft' NEAT PORTIANDCEMENT SLURRY(PUMP)
INMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if ri r dicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EiNIPLACEMENI'muniOD
❑Aquifer Test OStonnwater Drainage 78.0 f`• 119.0 f` 7-35(1k2) POUR
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION color,hardness,soil/rock ir're,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 f`• 40.0 ft- BROWN CLAY
4.Date Well(s)Completed: 12/08/22 Well ID# EX-22 40.0 ft- 115.0 ft• BROWN CLAYEY SANDY SILT
Sa.Well Location: 115.0 ft- 118.0 fr' PWR
DUKE ENERGY OF THE CAROLINAS ALLEN STEAM STATION 118.0 ft- 128.0 f` ROCK
Facility/Owner Name Facility I Dlt(if applicable) ft. ft.
253 PLANT ALLEN ROAD BELMONT 28012 ++ .
Physical Address,City,and Zip ft. ft. 1V 1 023
GASTON 304337 21.REMARKS
BENTONITE SEAL-73.0-78.0
Couaq' Parcel Identification No.(PIN)
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
STAINLESS STEEL SUMP - 118.0-119.0 FEET
(ifwell field,one lat/long is sufficient) 22.Certification: �,�G,�
528577.92155 N 1399929.36305 \\, '' 04/11/23
6.Is(are)the well(s): 051'ernianent or OTemporary Signature ofCcrtified Well Contractor Date
HP signing This form,I hereby Certify that the rrell(1)was 6r'ere)constructed in accordance with
7.Is this a repair loan existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C•,0200 Ide/I(otistrr+ctinn Standards and that a copy
!J'd+iv is a repair,Jill nut knoatr ire//c-onstrtic-liar irrfi)rmeiiioa and e.vp/win the+urn+rc,njdre of'ihis record has been provided to the well ou ner.
repair under:21 remarks,section or on the back oj'this Jnnn.
23.Site diagram or additional well details:
S.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction-only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'Sce Over'in Remarks Box).You may also attach additional pages ifnecessary
drilled. 24.SUBMITTAL INSTRUCTIONS
9.'Total well depth below land surface: 119.0 (ft-)
hor multiple ire/A list all depths ydtljerent(example-J a,200'and 2�t too') Submit this C\Y-I within 30 days of well completion per the follo�ti'ing:
11.46 24a. For All Wells: Original form to Division of Water Resources (DWR),
/i,Static water level iglus top of rising: (ft.) Information Processing Unit. 1617 MSC,Raleigh,NC 27699-1617
Ij u'a/er level is abate caving,use"- -
14.0/10.0/6.0 24b. For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
1 I.Borehole diameter: (in.) -
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/AIR/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
13a.Yield(gprn) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Amount:
Fotm GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2015