GW1--04172_Well Construction - GW1_20230706

. WELL CONSTRUCTION RECORD(GW-1) 'For-Internal Use Only: 1 •
1.Well Contractor Information: • •
r KENNY SARGENT
14,WATER ZONES. . -
Well Contractor Name .. FROM TO DESCRIPTION
ft. ft.
A - 4226 ;_ i':.,; ~` =F`) ft. tt. •
NC Well Contractor Certification Number �'�� £•"'�' �• `."' ' - - - -
15.OUTER CASING(for MUM-eased- 'wells)OR'LINER:(if ap licable) -
GEOLOGIC EXPLORATION I ( [� 6q(� FROM TO DIAMETER . THICKNESS . .MATERIAL
J�_ F} /`'�� ft. ft. in. -
•Company Name ... --• .-- - - - . . .
IrZ�;<f'i J. l �r •°ice. ,y UI ( -16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit# : C, 4-}O --' FROM TO • DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits(i e.'l./IC,County,ante,Varuance,etc.) ' O.0 ft• 64.0 ft. -2.0 in" SCH 40 PVC
3.Well Use(check well use): fr. ft: in.
17:SCREEN
Water Supply Well: • FROM TO DIAMETER SLOT SIZE THICKNESS ' MATERIAL
❑Agricultural ❑Municipal/Public 64.0 ft'.- 74:0 •ft' 2.0 in'. :010 SCH 40 PVC
•
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) . - ft. ft. in:
❑Industrial/Commercial - ❑Residential.Water Supply(shared)
18:GROUT •., ._ . .
❑Irrigation :. 'D Wells>100,000 GPD . . FROM TO MATERIAL , EMPLACEMENT METHOD&AMOUNT
Non;Water Supply Well: 0.0 ft. 56. ft 0 • PORTLAND BENTONITE SLURRY -
. -INMonitoring ❑Recovery . . ft. ft. .
Injection Well: - . - '
❑Aquifer Recharge .'❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)' •- - .-
❑AquiferStorage and Recovery - - ❑Salinity Barrier ' - -FROM TO ' MATERIAL EMPLACEMENT METHOD •
' - ❑Aquifer Test ❑Storlriwater Drainage 61.0 ft• 84.0 ft" 20-40, FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.- '
❑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,sailh ockrype,grain size,etc.)
.. - • 0.0 ft: '1:0 ft• GRASS/TOPSOIL
4.Date Well(s)Completed: 05/10/23 Well ID# PMW-U5-01 D . 1 0 ft. 11.0 ft' BROWN SILT
^� 5a.Well Location: 11.0 ft' 28.0 ft' BROWN SILTY SAND
CLIFFSIDE.STEAM STATION 28.0 ft• 32.0 ft• BROWN CLAY •
Facility/Owner Name Facility IDtl(if applicable) 32.0 ft• 68.0 ft' BROWN SILTY SAND
• 573 DUKE POWER ROAD .MOORESBORO 28114 68:0 ft... .74.0 ft.- - - BROWN SILTY PWR
Physical Address,City,and Zip - 74.0 ft. 84.0 ft. GRAY ROCK
RUTHERFORD
21.-REMARKS
County Parcel Identification No.(PIN) BENTONITE-SEAL- 56.0-61.0 FEET
•
Sb.'Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
***U-PACK SCREEEN.***
.\ (if well field,one tat/long is sufficient) 22.Certification'y� I/�r L 1`/ ^'
54558.5.8 N 1174361 W 05/15/23
•
6.Is(are)the well(s): Permanent or .❑Temporary Signature of Certified Well Contractor Date
By.signing this form,I hereby centt &that the well(s)was(here)constructed in accordance with
7.Is this a repair to.an existing well: ❑Yes or MNo ISA NCAC 02C.0100 or ISA NCAC 02C'.0200 Well Construction Standards and that a copy
If this is-a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner. I
repair under#21 remarks section or on the back of this•/arm.
23.Site diagram or additional well details:
8.For Geoprobe/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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in:Remarks Box).You may also attach additional pages if necessary
drilled: 24.-SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 74.0 (ft.)
. For nudtiple we/I.s list all depths ifdiffernn(example-3@200'and 2 a!no') - Submit this GW-1"within 30 days of well Completion per the following:
39,0 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 MSC,Raleigh,NC 27699-1617
!/'crater level is above casing,use'-
6,Q 24b. For Injection Wells: Copy to,DWR,Underground Injection-Control(IUC)
11.Borehole diameter: (in.) 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 GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018