NC0003433_Cape Fear AMEC Piezometer Installation Package CHATH-077_20150902

December 7, 2015 ameO
Mr. Dale Smith
Program Manager
Duke Energy
526 South Church Street
Charlotte, North Carolina 28202
Submitted by email: Dale. [e-mail]
Subject: Record of Piezometer Installation
Cape Fear Stearn Station 1970 Ash Pond
State Dam ID CHATH-077
Chatham County, North Carolina
AM EC Project No.: 7810-14-0154
Mr. Smith,
As part of the Reconstituted Design project for Cape Fear Steam Station (Cape Fear),
AMEC installed a total of three new piezometers in the existing 1970 Ash Pond (CHATH-
077). Details regarding the piezometer installation are attached including a location plan, a
summary table, field installation records, and well construction records. The
piezometers constructed in CHATH-077 were completed on December 18, 2014. It should be
noted, the proposed plan was to install four plezometers, however piezometer location CHATH-
077-PIOI was not accessible due to safety concerns and large trees, therefore, this piezometer
was omitted from this final package.
The piezometers (with the exception of CHATH-077-P101) were constructed in accordance with
the requirements of 15A NCAC Subchapter 2C — Well Construction Standards by a certified
well driller licensed in the State of North Carolina under the supervision of the Professional
Engineer (PE) licensed in the state of North Carolina whose seal is attached to this letter.
Details of the piezometers installed are attached and include field installation records reviewed
by the Engineer of Record (EOR) and well construction records prepared by the certified driller.
The field installation records are summarized in Table 1. The work was completed in
accordance with approved work plans and piezometer installations were completed with a
standard of care commensurate with accepted industry standards and in a manner that did not
alter the existing function or stability of the dam structure.
The piezometers were installed to provide data to be used during the Reconstituted Design but
are also intended for long term data collection by Duke Energy. AMEC will collect monthly
readings in the piezometers until March of 2015 at which time responsibility for obtaining the
readings will be transferred to Duke 'Energy personnel as a part of their plant specific
instrumentation monitoring program. Additional readings between the normal scheduled
frequency may be taken as deemed necessary to support data collection needs. Dupe Energy
shall maintain a record of the readings as part of their dam monitoring program that will be
available to the Division of Energy, Mineral, and Land Resources upon request,
Correspondence:
Anux Fosler Wheeler Environment Mi frastructurc, lne.
2801 Yt,rkt ono Road, 5uile 100
charlotte, North Camlina 28208
Tel [phone]
Fax [phone]
Fice:isure� NC Engitreering F-1253 NC Geology C-247

Record of Piezometer Installation — CHATH-077 Cape tear Steam Station
December 7, 2015 AMEC Project No.: 7810-14-0154
Page 2
Sincerely,
AMEC Environment & Infrastructure, Inc.
R. Bradford Tripp, P.E.
EOR- Project Engineer
Attachments:.
,�+yRi 141 1 1 1 1aY 1 r O'
K/-.01
r
Piezometer Location Plan, Figure 3
Summary of Piezometers Installed in 1956 Ash Pond, Table 1
Typical Piezometer- Field Installation Record, CHATH-077-P100
Well Construction Record, CHATH-077-P100
Typical Piezometer- Field Installation Record, CHATH-077-P102
Well Construction Record, CHATH-077-P102
Typical Piezometer- Field Installation Record, CHATH-077-P103
Well Construction Record, CHATH-077-P 103

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TYPICAL PIEZOMETER -FIELD INSTALLATION RECORD FLUSH MOUNT
JOB NAME Cape Fear Phase 2 Reconstitution of Ash Pond AMEC NUMBER 7810-14-0154
PIEZOMETER NO CHATH-077-P100 INSTALLATION DATE 12/18/2014
LOCATION- NORTHING: 667,949.5' FASTING: 1,984,891.9' GROUND ELEV: 195.35'
AMEC FIELD REPRESENTATIVE K. Charles -Smith DRILLER/ CONTRACTOR SAEDACCO
GRANULAR BACKFILL MATERIAL GP #2 Quartz Sand DRILLING TECHNIQUE Hollow Stem
SCREEN MATERIAL 2" I.D. Flush Joint Slotted PVC (Sch. 40 BOREHOLE DIAMETER 8" Nominal
SLOT SIZE 0.020" Machine Cut REFERENCE POINT" ELEVATION*
RISER MATERIAL 2" I.D. Flush Joint Solid PVC (Sch. 40 LUCK TYPE/KEY CODE Dolphin 1600
Preliminary -Final locationfelevation to be determined by As -Built Survey
Rererence point is notch cut in the top of PVC casing
WELL CAP s
BOLTED FLUSH MOUNT COVER
(approx. 1' BELOW GRADE)
CONCRETE PAD
(2'X2'X6")
GROUT
DEPTH TO TOP OF
BENTONITE SEAL.
= 14.5 FEET
BENTONITE SEAT. (Min. 3 feet)
DEPTH TO TOP OF
GRANULAR MATERIAL
= 17.5 FEET
SCREEN
GRANULAR BACKFILL
CENTERING DEVICES INSTALLED
(APPROXIMATE DEPTHS)
- N/A
SUMP/CAP
s
i
Site Manager Review
NOTE: NOT TO SCALE, ALL DEPTHS RECORDED
ARE RELATIVE TO EXISTING GROUND SURFACE
AT TIME OF INSTALLATION
LENGTH OF RISER/
SOLID SECTION
21.0 FEET
DEPTH TOP OF
SCREEN SECTION
21.0 FEET
LENGTH OF SCREEN/
SLOTTED SECTION
10.0 FEET
DEPTH BOTTOM OF
SCREEN SECTION
31.0 FEET
TH OF SUMP & CAP
FEET
A
In 44
10
GROUND
TOTAL DEPTH
OF PIEZOMETER
31.0 FEET
STABILIZED WATER
LEVEL AFTER
DEVELOPMENT
N/A FEET
BELOW TOP OF
STICKUP
MEASURED ON
N/A DATE
BOTTOM OF PIEZOMETER
AMEC_ Well Insfallalfon Record,, Rev 0

WELL CONSTRUCTION RECORD
This fowl ran be used for single or mulliple wells
For hnemal Use O LY:
1. Well Contractor Information:
Randy D, Hoffman
Welt Contractor Name
3476
INC Wei[ ConlructorCertification Number
SAEDACCO
Company Name
2. Well Construction Permit #:
List all applicable it -ell lama mils (l. e. 170111•, State, 11611aaee, 1"*010n, arc)
3. Well Use (check v+rll use):
►eater supply LYell:
❑Agricultural
❑Geothermal (Heating+Cooling Supply)
O lndustriallCotm nerc i ai
❑MunicipaUPublic
❑Residential Witter Supply (single)
❑Residential Water Supply (shared)
Non -Water Supp1F Wdl:
O Monitoring ❑ Recovery
DAquifer Recharge
OAquiter Storage and Recovery
❑Aquifer Test
DExperimental Technology
13Gcothernial (Closed Loop)
©Geothermal fi3ealimt/Cooline
❑Ciroundwater Reined iation
DSalinity Barrier
OStor water Drainage
❑Subsidence Control
❑Tracer
❑Other {explain tinder #21 8
4. Date Well(s) Completed: 12/18/201444'ell. 1D# CHATH-077-P1 QO
5a. Well Location:
OUXE ENERGY - CAPE FEAR STEAM STATION
Facility/OEvner Name Facility ID# Iifdppiicable)
500 CP&L ROAD, MONCURE, NC 27559
Physical Address. City. and Lip
CHATHAM
County
Parect Identification No. (PIN)
5b. Latitude and Longitude in degreeslminuteslseconds or decimal degrees:
(ifwell Field, one laillong is sufficient)
350 35' 07.04" N 790 03r 02.93" W
6. Is (sere) the►vell(s): OPermancut or ❑Temporary
7. 1s this it repair to an existing ►vela: ❑Yes or ❑No
If thlr is a rel4or, Jill ow ,tur,,,n weft C-uVrurth l) infurotaliou anal erplaltt Cite xcrtirre oj'(ite
repair under #21 remark section or ore Nte hark olihis form.
S. Number of wells constructer!: 1
F`or multiple it jev;tiott ar ttwr-rratrr.suPl ly ua•Ils 01VL )' a ith the same construction, you tvui
suhaiii one form.
9. Total well depth below land surface: 31 '0
Far nudliple irells list all deplhs if dV/erern ferample- 7 r;?Rnand 2(a4o0')
10. Static water level below top of casing. NIA
11 lsaner level is ahaiv rashtg, nse "* "
IL Borehole diameter: 8 fill.)
(ft.)
14,WATCIt
ZCN ES
FROM
TO
DESCRIPI]ON
ft.
fL
-
ft.
ft.
I5. UL7 J;R C:4C1\(; tfartantti-c>tied
vrettsy UFt L.ItiER (it a r Rca6lxy
FROM
TO
Ikt%-METER
THtCIi,'4ES5
n1A1`£RIA7.
0,0 rt.
21.0 R.
2 in.
SCH 40
PVC
16. INNER CASING OR f 'RING tccoflrermel alosrd4oa )
FRCsit T6
n1,L31E11:1k
THICKNESS MAYEn1.4I,
ft. fk.
in.
ft. I.
in
17. SCREEN
FROM
TO I
nIAMFI"ER
S1,01 SIZE
-tHICKNESS
MA VENIAL.
21.0 ft'
31.0
2 i°-
0.01
SCH 40
PVC
fF.
tt.
in.
is. GROLT
FROM
TO
MATERIAL
E41PI.,%CE%IENtrilE1HOAf,LhtULINT
ft.
fk.
ft.
II.
R.
ft.
19. &kNViGRA4►-EL PACK
)
FRrs41
TO
I MATERIAL I
EMPLACEMENT METHOD
17.5 it.
31.0 ft
Quartz Sand
ft.
rk
so. tIRiLLI'tG LOG (ssttacll
add] sLeeu 11 ceeeuakv
FROM
TO
pESCR1PTIoiV color, hardness. sasUruck f. r, r�ira sire, crc.t
ft.
ft.
ft,
fi,
ft.
ft.
ft.
ft.
ft.
ft,
ft.
ft.
ft.
ft.
3 PJE.NlAPKS
BENTONITE SEAL, FROM 14.5 TO 17.5 FEET
22. Certification:
tRaor4 sq-i4 a llu
Signature of Ccnif ed Well Contractor
12-18-2014
lisle
8-v xigning this form, I herein- eervi& that the icell(s) asps (were) consirarted m atTwiltatce
ivillr 15A NCAC 02C.0100 ar 15A AC -IC 02C .0200 Ii ell Consinictfon Standards and that a
ropy ofthis record has been provided to the urlf onvter.
23. Site diagram or additional well details:
You may use the back of this pare to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INISTUCTIONS
241. ror All Wells: Submit this form withal 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24h„ For Infection Wells ONLY: In addition to sending the form to the address in
AUGER -49 Move, also stihino a copy of [his form v►•ithin 30 days of completion of well
12. Well construction method: construction to the following:
i,u. auger, rotary, cable„ dircct push, etc_)
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpin) Method of test: 24c. For Witter Supply _& Injection Wells:
Also submit one copy of this fowl within 30 days of completion of
13b. Disinfection type. Amount.- well constriction to the county health department of the county where
constructed.
Forin CiW-I Nardi Carolina Department of Envirunmeni and Natural Resources - Division of Water Resources Revised August 2013

TYPICAL PIEZOMETER -FIELD INSTALLATION RECORD (FLUSH MOUNT)
JOB NAME Cape Fear Phase 2 Reconstitution of Ash Pond AMEC NUMBER 7810A4-0154
PIEZOMETER NO CHATH-077-P102 INSTALLATION DATE 12118/2014
LOCATION- NORTHING: 666,990.0' FASTING: 1,985,800,6' GROUND ELEV. 186,03'
AMEC FIELD REPRESENTATIVE K. Charles -Smith DRILLER/ CONTRACTOR SAEDACCO
GRANULAR BACKFILL MATERIAL GP #2 Quartz Sand DRILLING TECHNIQUE Hollow Stem
SCREEN MATERIAL 2" I.D. Flush Joint Slatted PVC (Sch. 40) BOREHOLE DIAMETER 8" Nominal
SLOT SIZE 0.020" Machine Cut REFERENCE POINT"" ELEVATION'
RISER MATERIAL 2" I.D. Flush Joint Solid PVC (Sch. 40 LOCK TYPEIKEY CODE Dolph'In 1600
Preliminary -Final locationlelevation to be determined by As -Built Survey
*' Reference point is notch cut in the top of PVC casing
WELL CAP
BOLTED FLUSH MOUNT COVER
(approx. 1' BELOW GRADE)
CONCRETE PAD
(2'X2'X6")
GROUT
DEPTH TO TOP OF RISER
BENTONITE SEAL
15.0 FEET
BENTONITE SEAL (Min. 3 feet)
DEPTH TO TOP OF
GRANULAR MATERIAL
18.0 FEET
SCREEN
GRANULAR BACKFILL
CENTERING DEVICES INSTALLED
(APPROXIMATE DEPTHS)
NIA
r
NOTE: NOT TO SCALE, ALL DEPTHS RECORDED
ARE RELATIVE TO EXISTING GROUND SURFACE.
AT TIME OF INSTALLATION
GROUND
TOTAL DEPTH
OF PIEZOMETER
LENGTH OF RISER/ 30.0 FEET
SOLID SECTION
= 20.0 FEET
DEPTH TOP OF
SCREEN SECTION
20.0 FEET
LENGTH OF SCREEN/
SLOTTED SECTION
10,0 FEET
DEPTH BOTTOM OF
SCREEN SECTION
- 30.0 FEET
C14�TH OF SUMP & CAP
�O.? FEET
SUMP/CAP
STABILIZED WATER
LEVEL AFTER
DEVELOPMENT
NIA FEET
BELOW TOP OF
STICKUP
MEASURED ON
= N/A DATE
SEAL BOTTOM OF PIEZOMETER
ame
Site Manager Review -4 Date: 1 /7 /JS .
AMEC—Well lnslallaUan record, Rev 0

WELL CONSTRUCTION RECORD
This form can be used for single or multiple hells
I. Well Contractor Information:
Randy D. Hoffman
Well Contractor Name
3476
NC Well Contractor ( eniikaiion Number
SAEDACCO
Company No tile
2. Well Construction Permit #:
List all applicable hell pernpits (Le, County. State, Variance, Injection, ere)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
DGeothmmal (1-leatinglCooling Supply)
17 Industrial/Conimcreial
❑ Irrigation
Nan -►Water Suppl.s Well:
❑Aquifer Recharge
©Aquifer Storage and Recovery
❑Aquifer Tess
❑Experimental Technology
❑Gewhermal (Closed Loop)
013cothemtal (Heatinrr'Ctxiline
❑141unicipaU'Public
[]Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
13Groundwater Remedial ion
❑Salinity Barrier
13Stormwater Drainage
QSubsidence Control
UTraccr
13t7ther(explain tinder421 Remarks1
4. Date Well(s) Completed; 12/18/2014►yell ID# CHATH-077-P 102
5a. Well Location:
DUKE ENERGY - CAPE FEAR STEAM STATION
Facilily)Oumcr ]dance Facility IDP (if applicable)
500 CP&L ROAD, MONCURE, NC 27559
physical Address, City, and Zip
CHATHAM
County
Parcel Identification No- (PIN)
Sh. Latitude and Longitude in degrees/niinuteslseconds or decimal degrees:
(iftacll field, one latltonb is sutlicienl)
350 34' 57,56" N 79" 02' 51.92" �v
b. Is (are) the tvell(S): ft7Pernmrient or OTemporory
7. Is this a repair to an existing well: ❑Yes or VINo
If this is a repair,,liii out knoynr well currstrr+rrian Infilvinarion dial explalps the nanrre y (11re
repair under #21 remarks seetian or on the hack of Phis form.
S. Number of wells constructed: 1
Far audliple Injection or nou-sorer supply, tivils ONLY yvilh dw saute coustruedon, you can
submit one form.
9, Total well depth below land surface: 30.0
Por• nadtl),le „-eil-q Iter rill depths Ifclifl"erew (example- 30, 200' and2(ezjliio'l
10. Static water level below top of casing: NIA
lfi;wur let.ef is obare rasing, use "t "
il. Borehole d'larneter: 8
12. Well construction method: AUGER
(i.e. auger, rotary, cable, direct push, etc-)
(ft.)
For Internal Use ONLY
14. ►VATER MNES
FROM TO BESCRIPTIOY
ft. ft.
ft. ft.
IS.0 UTERC%,MNG
rRa�r To for_mells))RLINFJIra tumbler
m�edr_
THIClcNM i MATERIAL
SCH 40 PVC
114. INNER C.4WG OR TURING fecotilcrmal doffed Too i
FRONI TO nlAMETElt I THICKNESS hlAl"ERIAL
ff. ft. In.
CI. m in
17. aCREE2�t
FROM TO OIAMEI ER $1-03 SIZE. 'I HICKSESS MA I ERIAL
20.0 ft 30.0 2 Ia' IN SCH 40 PVC
fL ft. in.
is. GROUT
FROM TO MATERIAL EMPLACEMENT AIErnga & AmlaunT
ft. tt.
ft. ft,
ft. ft.
19. SXNBAMU'%1EL F-AC Iffauidicablo
FROM TO MATERIAL F-SIPLACEAIE}T.1IETIIOft
18.0 rr. 30.0 ft, Quartz Sand
ft. ft.
20. DRILLING LOG (Attach Addidaml sbeere Ifnecetsa
FROM TO DESCRIPTION color, bnrdncss, soillrnsf; e, ginifn rlac, etc.)
ft. ft.
ft. ft.
ft. rt.
ft. fl.
fL ft.
ft. ft.
ft. ft.
21. RE` I %RKiS
BENTOMTE SEAL FROM 15.0 TO 18.0 FEET
22. Certification;
tR4n4 qf,4-ao 12-18-2014
Signature or Certified Well Contractor Bate
By signing flux fnrur, I heretic cvrry, • that the rrell(s) teas (here) consniweed is accordance
with 15.4 NCAC 02C -a100 or 13A NCJC 02C.0d00 Well Canstruclion Sfnadards and dtol a
copy ofth[s record has been provided to die tee 11 oswer.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details- You may also attach additionai pages ifnecessary.
SUBMITTAL INSTUCTIONS
24a. For All ►Yells: Submit this form within all clays of completion of well
CORNITI letit3n to the following:
Division of Water Resources, Information Processing Unit,
tfr17 Mail Service Center, Raleigh, NC 27699-1617
24b. For luiection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the follotting:
Division of Water Resources, Underground Injection Control Program
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
130. Yield (gpm) Method aC test: Also submit one copy of this form within 30 days of completion of
13b. Disinfectiou type: Amount: well construction to the county health department of' the county cohere
constructed.
I'omt GW-I North Carolina Department ofCnvironment and Natural Respurces -Division ofWawr Resources Revised August 2013

TYPICAL PIEZOMETER -FIELD INSTALLATION RECORD FLUSH MOUNT
JOB NAME Cape Fear Phase 2 Reconstitution of Ash Pond AMEC NUMBER 7810-14-0154
PIEZOMETER NO CHATH-077-P103 INSTALLATION DATE 12117/2014
LOCATION- NORTHING: 666,961.6' EASTING, 1,985,795.0' GROUND ELEV: 180.67'
AMEC FIELD REPRESENTATIVE K. Charles -Smith DRILLER/ CONTRACTOR SAEDACCO
GRANULAR BACKFILL MATERIAL GP #2 (Quartz 'Sand) DRILLING TECHNIQUE Hollow Stem Au
SCREEN MATERIAL 2" I.D. Flush Joint Slotted PVC (Sch. 40 BOREHOLE DIAMETER 8" Nominal
SLOT SIZE 0.020" Machine Cut REFERENCE POINT— ELEVATION"
RISER MATERIAL 2" I.D. Flush Joint Solid PVC (Sch. 40 LOCK TYPE/KEY CODE Dolphin 1600
Preliminary -Final locationlelevation to be determined by As -Built Survey
Reference point Is notch cut in the top of PVC casing
WELL CAP
BOLTED FLUSH MOUNT COVER
(approx. V BELOW GRADE)
CONCRETE PAD
(ZX2'X6")
GROUT
DEPTH TO TOP OF RIS
BENTONITE SEAL
4.5 FEET
BENTONITE SEAL (Min. 3 feet)
DEPTH TO TOP OF
GRANULAR MATERIAL
7.5 FEET
SCREEN
GRANULAR BACKFILL
CENTERING DEVICES INSTALLED
(APPROXIMATE DEPTHS)
NIA
earl �
r
NOTE: NOT TO SCALE, ALL DEPTHS RECORDED
ARE RELATIVE TO EXISTING GROUND SURFACE
AT TIME OF 'INSTALLATION
LENGTH OF RISER/
SOLID SECTION
- 9.5 FEET
DEPTH TOP OF
SCREEN SECTION
9.5 FEET
LENGTH OF SCREEN/
SLOTTED SECTION
- 10.0 FEET
DEPTH BOTTOM OF
SCREEN SECTION
- 19.5 FEET
.tip •_
TH OF SUMP &CAP
62 FEET
SUMP/CAP
GROUND
TOTAL DEPTH
OF PIEZOMETER
19.5 FEET
STABILIZED WATER
LEVEL AFTER
DEVELOPMENT
N/A FEET
BELOW TOP OF
STICKUP
MEASURED ON
N/A DATE
SAL BOTTOM OF PIEZOMETER
`t
6J�J"�j/ Gfr......
am `�`�*airy }y.t©�4,
�,�►i���ii %%%
Site Manager Review [' 5 1 A Date; ! b/`.-
AMEC Well lnstadah'oo Record, kav o

WELL CONSTRUCTION RECORD
This form can he rims) for single or ntsitiple wails
I. Well Contractor Information:
Randy D. Hoffman
Well Contractor Name
3475
NC Well Contraclor Certification Nurnher
SAEDACCO
Company blame
2. Well Consh•uction Permit #:
List all alydieahle stellperrni7r (i.e, Catntn•, Stole, Parlance. Irtfeetion, etc.)
3. Well Use (check well use):
Water Supply Well;
DAgricnitural ❑iblunicipallPublic
❑Geothermal (IleatinglCo©ling Supply) []Residential Water Supply (single)
❑lndustriallCommercial ❑Residential Water Supply (shared)
Clirri ation
Non -Water Supply Well:
VINIonitoring ❑Recovery
Injection Well -
❑]Aquifer Recharge OGroundwater Remediatilm
❑Aquifer Storage and Recovery ❑Salinity Barrier
ClAquifer Test ❑Stormwater Drainage
DExperimentaI Technology ❑Subsidence Control
❑tacothernml(Closed Loop) 13Tracer
ClGeothermal (FleatinglCooling Return) ❑Other (expiain under 421 Remarks)
4. Date wells) Completed: 12/17/2014 Well 1DY OATH-077-P103
5a, Well Location:
DUKE ENERGY - CAPE FEAR STEAM STATION
Facility/Owner Name Facility ID# (if applicable)
500 CP&L ROAD, MONCURE, NC 27559
Physical Address. City. and Zip
CHATHAM
County P..Wel Identification No. (PIN)
Sh. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
tifwell field„ one lautong is sufficient)
350 34' 57.28" N 790 02' 51.99" W
6. Is (are) the well(s): G]Permanent at, ❑Temporary
7. Is this a repair to an existing well: CiYes or ®No
if ilia' is a repair, fill ora komm well con tr ucrian lnformauou and exph hr the mature gj"lhe
repair antler N21 rctuar'ks srrtiart or on the ht k of iris form.
8. Number of wells constructed: I
For multiple injtwlion or non -"rarer sapph• svelle ONLY Will the suine eonsfrrrctinu. vancum
submit our form.
9. Total well depth below land surface: 19.5
For tnrdiple ivells list all depths !f`dif Brent (rerrrnple- ; Cq2 of)' 'an,/ 2in.11)011
110. Static water level below top of easing: N/A
Ifwilerlevel is shave rasing, use
11. Borehole diameter: 8
Fur hNerrsal I,+se t71V1.'s';
1.1. M %T-ER ZONUS
FrtOdl
11)
nESCRIPTIO,
A.
ft.
ft.
ft.
15.OMR CASING for inalt3ascd tieil,0OR LINEK It it I"Mr
rkMcl
FROJt
TO _
nI LR I
THICKNESS MATERIAL
0.0 ft.
9.5 R.
2 in.
SCH 40 PVC
to.1XVIKK CASING OR ItBING eallierinal elased-lart l
FROM
TO
I)L MET'ER I
THICKNESS
I MATERIAL
ft.
il.
In,
ft.
1T. SCR F€``
t RO,tl I
TO nIA1,I14-1 kIt
st.0l'SIZE
-ITRCK'NES5
MATERIAL
9.5 rt.
19.5 It. 2 in•
0.01
SCH 40
PVC
ft.
1It. GROLT
FROM
TO
MAI ERIAL
LMI'LAC'SAIE:.NT MET1100 & AATOUNT
0.0 rt°
4.5 et.
Cement
Slurry
rr.
el.
rr,
rr.
I Y.StNl)[:RtikL P ACf►
ifx licablel
1:KOiS
I I
ALATERLkL
EAIPLACEAIEti'i .'qET1Con
7.5 n°
19.5 e' I
Quartz Sand
ft,
I ft.
20. DRILLING LOG tatboch additional sheets ifn cessarvl
FROM
TO
DESCRIPTION (mta r, hardntxv, aalllrock ts', grin size, etc.)
ft.
It.
fl.
ft.
ft.
fl.
ft.
et.
ft.
ft.
ft.
ft.
ft,
ft.
BENTONITE SEAL FROM 4.5 TO 7.5 FEET
22. Certification:
Ra 'W0#0cam 12-17-2014
Signature of Ceni4ied Well Contractor hate
Br signing this fin-ni, l herobi. cerrjv that ire iselliel war (ssrre) ronstrucicul ilr acc•urdrturc
wile 15.4 NCIC 02C MnO or^ 15A NCdC 02C .0201) Well Corrstruerlon Srcindgtrrls auul thal a
calf)• ofilris record lrus lreeulrrovided to the sell ouuer.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
cons tntclion details. You may also attach additional pages if necessary.
SUBMITTAL Ii\STUCTIONS
24a. For All Wells: Submit this form NAthin 30 days of completion of well
construction to the following:
(ft.) Division of Water Resources, Information Processing Unit,
1617 ;flail Service Center, Raleigh, NC 27699-1617
24b. Fur Injection Wells ONLY: In addition to sending the form to the address in
AUGER 24a above, also submit a copy or this form within 30 days of completion of well
12. Well construction nlethotl: construction to the following:
ll•c. anger, rotary, cable, direct posh, etc.)
Division or Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: 24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b. Disinfection type: Arununt• well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Oeparu Gent of Enviroantent and Natural Resources - Division of Water Resources Revised August 2013