NC0003433_Cape Fear AMEC Piezometer Installation Package CHATH-079_20150902

December 7, 2015
Mr. Dale Smith
Program Manager
Duke Energy
526 South Church Street
Charlotte, North Carolina 28202
Submitted by email: [e-mail]
Subject: Record of Piezorneter Installation
Cape Fear Steam Station 1985 Ash Pond
State Dam ID CHATH-079
Chatham County, North Carolina
AMEC 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 six new piezometers, in the existing 1985 Ash Pond (CHATH-
079). 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-079 were completed on December 18, 2014,
The piezometers 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 piezorneters 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. Duke 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:
Arnee Foster Meeler Environnwnt &JInfrastruclure, Inc.
2801 Yorkmont Road, Suite. I W
Charlotle, North Carolina 28208
Tel [phone]
Fax [phone]
1-iceiisure:NCEtiginceriiio,,F-1253 NC Geology C-247

Record of Piezometer Installation — CHATH-078 Gape Fear Steam Station
December 7, 201, 5 AMEC Project No.: 7810-14-0154
Page 2
Sincerely,
AMEC Environment & Infrastructure, Inc.
E�
R. Bradford Tripp, P.E.
EOR- Project Engineer
Attachments:
Piezometer Location Plan, Figure 2
Summary of Piezometers Installed in 1956 Ash Pond, Table 1
Typical Piezometer- Field Installation Record, CHATH-079-P100
Well Construction Record, CHATH-079-P100
Typical Piezometer- Field Installation Record, CHATH-079-P101
Well. Construction Record, CHATH-079-P101
Typical Piezometer- Field Installation Record, CHATH-079-P102
Well Construction Record, CHATH-079-P102
Typical Piezometer- Field Installation Record, CHATH-0739-P103
Well Construction Record, CHATH-079-P103
Typical Piezometer- Field Installation Record, CHATH-079-P104
Well Construction Record, CHATH-079-P104
Typical Piezometer- Field Installation Record, CHATH-0789-P105
Well Construction Record, CHATH-079-P105

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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-079-P100 INSTALLATION DATE 12/1812014
LOCATION* NORTHING: 669,306.1' FASTING: 1,9$7,629.6' GROUND ELEV: 193,35'
AMEC FIELD REPRESENTATIVE B, Weyer 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 LOCK TYPE/KEY CODE Dolphin 1600
' Prellminary-Final locationtelevation 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. I'BELOW GRADE)
CONCRETE PAD
(2'X2'X6`)
GROUT'
DEPTH TO TOP OF Mohr%
BENTONITE SEAL
8.0 FEET
93ENTONITE SEAL (Min. 3 feet)
DEPTH TO TOP OF
GRANULAR MATERIAL
13.0 FEET
SCREEN
GRANULAR BACKFILL
CENTERING DEVICES INSTALLED
(APPROXIMATE DEPTHS)
= NIA
Ills] ,
ameo
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/ - 25.4 FEET
SOLID SECTION
- 12.0 FEET
DEPTH TOP OF
SCREEN SECTION
15.0 FEET
LENGTH OF SCREEN/
SLOTTED SECTION
- 10.0 FEET
SUMP/CAPS ;,?t
039171
j'ljI8111111ti1:,
Site Manager Review
7I
DEPTH BOTTOM OF
SCREEN SECTION
25.0 FEET
I OF SUMP & CAP
FEET
STABILIZED WATER
LEVEL AFTER
DEVELOPMENT
N/A FEET
BELOW TOP OF
STICKUP
MEASURED ON
- NIA DATE
BOTTOM OF PIEZOMETER
AMEC Waff ffWaNettcr; Record, Rev 0

WELL CONSTRUCTION RECORD
I[& form can be used for single or multiple wells
For [totemat Use ONLY;
1. Well Contractor Information:
Stefan J. Smith
Well Contractor Nam
3576
NC Well Contractor Certification Numlvr
SAEDACCO
Company Name
2, Well Construction Permit #:
Liss! all apphrahle well permits (i. e. Catmr(V, VON, Variauler- Inferflon, ete)
3, Well Use (check well use):
Water Supply Well:
❑Agricultural
00cothernaal (Heating/Cooling Supply)
Q Ind usiri allCom mere i a l
Plan -Water Supply Well:
Injection Well:
t7Aquifer Recharge
11Aquifer Storage and Recovery
QAquifer Test
QExperinicnial Technology
0Gcothemial (Closed. Loop)
[]Geothermal (Heating/Cooling Return)
DMun"lcipallPublic
❑Residential Water Supply (single)
DResidcntial Water Supply (shared)
O Recovery
ClGroundwaler Rernediation
❑Salinity harrier
QStonnwater Drainage
OSubsidence Control
I]Traccr
DOdier(explain Linder #21 Remarks)
4, Date Well(s) Completed: 12/18/2014Well ID# CHATH-079-P1 OO
5a. Well Location:
DUKE ENERGY -CAPE FEAR STEAM STATION
Facilirylt)wner Name Facility fl)f (ifapplicubIv)
500 CP&L ROAD, MONCURE, NC 27559
Physical Address, City, and Zip
CHATHAM
County
Parcel Wntificallon No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds nr decimal degrees:
Cif well field, one lau'long k sufficient)
350 _144r 90 AR" 700 (191 7t1 74"
N
W
la. WATER ZONES
FROM
TO
DESCRIPTION
rut.
ft.
ft.
ft.
15. OUTER C.kSING for multkased aeR_t DR
IXNER applicable)
FROM_
I To
-_ DIAMETER _
TtnCKNESS bust-f_E_RiAL
0 ft,
1,5 ft.
2 in,
SCH 40 PVC
16. LNNER
c.tiSL`tG dR rut 81`tc therm
it dosed -loop)
FROM
I 1'o
I DIAMETER I
THICKNESS
I 1t;ATUHAL
fs,
ft,
I in,
ft.
ft.
17. SCR£F-%
A R04"1
110 Ut.A,11 F. I-LR
SLal"SIZE
II1ICKNESS
MATERIAL
15 il.
25 r1. 2 lit.
0.02
SCH 40
PVC
ft.
it. in.
18. GROIJ
FRf1111
I TO
AIATERIAL
EhIPLAcrNIENT MET140D se AMOUNT
0 ft,
8 et.
cement
Slurry
it.
fZ.
ft.
ft.
19. SAND GFLA k-EL PACK
01'appikablel
FROM To
MATERIAL ENIPLACEMENT METHOD
13 ft, 25 rr.
quartz Sand
ft. rt.
20. URILLLXG LOG (attach atfditinual shetts 1f aecessary
FRIXM
TO
DE5CRIPTION("Inr,hardn�4%.suitiruekty e, gminsize^,rtt.l
ft.
ft.
ft.
ft.
ft,
ft.
ft.
ft.
ft.
ft.
ft.
ft
rt.
ft.
21. RE►l a:R10. -
BENTONITE SEAL FROM 8.0 TO 13.0 FEET
22. Certification:
szt cj" .5-etd
Signature ofCenifred Well Contractor
12-18-2014
[late
6. is (are) the Ive11(s): 10Pernmancnt or [ITemporai y far ,signing this farm, I hereby cert#.v Thor the "elks) waF (n erel constructed in urrvrrshurre
with 15A NCAC 02C.0100 or 15A NC IC 02C .tl2ta Well Consrrurtion Standw els ford that a
7, Is this a repair to an existing well: QYes or 0No evl?rvfWx recordhat been providedto the ww Unwrner.
ljrhis m a repair. fill outbaoim ww+rfl cwnstr uctiou inf-otiaa and r.Tplahi the rnrarre of the•
repair wider #21 re nwrkv.sertiou or at Ike back ufrhLr Jarm. 23. Site diagram or additional well details:.
You may use the back of this page to provide additional well site details or well
8. Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple itymsion or non-maer .vupplr wells ONLY ivnh the same cvnsrmcaorr, you can
subw0 our farm. SUBMITTAL I,NSTUCTI ONS
9. Total well depth below land surface: 25.4
Far nndtipfe iuef v list rill depl6v if4ger•rmr (example- 7r r:?00I arnl2@10iry
10. Static water level below top orcusing. NIA
If wvater lew el is above ratting, uve "+"
11. Borehole diameter: B (in.)
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the Following -
Division of Water Resources, Information Processing Unit,
16I7 Mail Service Center, Raleigh, NC 27699-I6I7
24b. For Iniection Wells ONLY: In addition to sending the forth to tho address in
AUGER 74a above, also submit a copy of this form kiithin 30 days of completion of well
12. Well constructing nlethad: constntclion to the following:
Ii.c. auger, miary, cable, direct push, etc-)
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1616 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpin) Method of test: 24c, For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
13h. Disinfection type: Amount: well construction to the county health department of the county where
eonstrcted.
Form GW-I Nurib Carolina ❑epartatcn1 of Cnvironmeni and Nulural Resources- Division of Water Resources Revised Aug"t 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-079-P101 INSTALLATION DATE 12/1812014
LOCATION" NORTHING: 668,386.4' EASTING: 1,988,221.8' GROUND ELEV: 193.29'
AMEC FIELD REPRESENTATIVE B. Weyer DRILLER/ CONTRACTOR SAEDACCO
GRANULAR BACKFILL MATERIAL GP #2 (Quartz Sand) DRILLING TECHNIQUE Hollow Stem Au
SCREEN MATERIAL 2" I.D. Flush Joint Slatted PVC (Sch. 40) BOREHOLE DIAMETER 8" Nominal
SLOT SIZE 0.020" Machine 'Cut REFERENCE POINT" ELEVATION'
RISEN MATERIAL 2" I.D. Flush Joint Solid PVC (Sch. 40) LOCK TYPEXEY CODE Dolphin 1600
Preliminary -Final location/elevation to be determined by As -Built Survey
" Reference point is crotch 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 RI
BENTONITE SEAL
13.0 FEET
BENTONITE SEAL (Min. 3 feet)
DEPTH TO TOP OF
GRANULAR MATERIAL
18.0 FEET
SCREEN
GRANULAR BACKFILL
CENTERING DEVICES INSTALLED
(APPROXIMATE DEPTHS)
= N/A
Yl4T[
r
NOTE: NOT TO SCALE, ALL DEPTHS RECORDED
ARE RELATIVE TO EXISTING GROUND SURFACE.
AT TIME OF INSTALLATION
LENGTH OF RISERI
SOLID SECTION
15.0 FEET
DEPTH TOP OF
SCREEN SECTION
- 20.0 FEET
LENGTH OF SCREEN/
SLOTTED SECTION
10.0 FEET
Jar
DEPTH BOTTOM OF
SCREEN SECTION
30.0 FEET
'kEpCyTH OF SUMP & CAP
SUMP/CAP ►'; . s FEET
tZ Y.
GROUND
TOTAL DEPTH
OF PIEZOMETER
- 30.4 FEET
STABILIZED WATER
LEVEL AFTER
DEVELOPMENT
N/A FEET
BELOW TOP OF
STICKUP
MEASURED ON
N/A DATE
SEAL - BOTTOM OF PIEZOMETER
amelo "DFmcl
!} f ! 'Al
Site Manager Review IL �i
AMEC Weil iRNNUarion Record, Rev D

WELL CONSTRUCTION RECORD
This torn can be used far single or multiple wells
1. Well Contractor Information:
Stefan J. Smith
Well ContraclorNamc
3576
NC Well Contractor Certification Number
SAEDACCO
Company Name
2, Well Construction Permit #:
44vt al/ applicable srelf peonds (Le. Carrrrtt. Slate, Variance, bye, tiara, elc.)
3, Well. Use (check well use):
Water Supply Wcll:
[]Agricultural
❑Geothermal (FleatinglCooling Supply)
❑ 1n d ustriallC ommercia l
❑Irrigalion
Non-1Vater Supply Well:
C3+ lvIonitoring
Injection Well:
IJAquifer Recharge
D.Aquifer Storage and Recovery
❑ Aquifer -rest
❑Experimental Tecimolofry
DGeothermaI (Closed loop)
ClGeotherlmal fficatinuJCoulinl Returnl
❑municipaUPublic
❑Residential Water Supply (single)
ElRes ident ial Water Supply (shared)
❑ Recovery
❑Groundwater Remediation
❑Sa[in ily Barrier
❑Stonmwater Drainage
❑Subsidence Control
❑Tracer
❑G[her (explain under #21 Remarks)
4. Date Well(s) Completed: 12/1812014 Well ID#1 CHATH-079'-P101
Sa. Well Location:
DUKE ENERGY- CAPE FEAR STEAM STATION
Faeilily/Owner Name Facility 1DN (if applicahle)
500 CP&L ROAD, MONCURE, NC 27559
Physical Address. City, and Zip
CHATHAM
County Parcel Identification No. {PIN)
5b. Latitude and Longitude in degreesfminutesfsetonds or decimal degrees:
(if well field, one larrlong is sufficient)
350 35' 11.38" N 790 02' 22.61" `ti
6. Is (are) the well(s): i7Permonent at- ❑Temporary
7, Is this a repair to as existing well: Dyes or RINa
Ifthls is a rep in fill Sal know[ Well C"'Isiraetlwr fnfunnurion aold eplaNr life Plana?" aJ the
repair raider N21 reararkr section or our the hack of this frrim
8. Number of wells constructed: I
For ntultlpie h yecilarr or rraa-Wxarcr.surplt uefdr O;VLy sirith rho surge C0r1srr$1Vd rrl, tinu Vail
suhn+il Sue farr[r_
For Internal Usc ONLY?
14, %V,%'1'ER 7.0XES
FROM TO DFSCRIMON
ft. fit,
rL fir,
HAIL `rERCASING for maltf -,, odwe7WO RLINER f• licalrle
FROA1 TO D[A�IFT" THICKNESS MATrRLILL
0 ft. 20 ft. 2 In, SCH 40 PVC
16. INNER CASING OR TL HING I enthermat dosed-loo I
FROM TO UTAMETFT, Tfllck.4ESS LNIATERLtL
Ft, ft. In.
ft. tt. In.
17. SiCVXEN
FRO\I TO DIAMETER SLO1'SIZE Tn1CKNESS h1AIERIAL
20 n. 30 R. 2 in. 0.02 SCH 40 PVC
ft. ft. in.
1N. GROL T
FROM r0 MATERIAL EAtPLACEMEN [ METttOD & AMOUNT
0 Ft. 13 Cement Slury
ft. ft.
fir. fit,
19.SAPxll:"ckiN-EL PACK IIIo licwble)
FROM TO NIA-1 EMPLACEMENT MET1tOD
18 fit. 30 fir, Quartz sand
ft. ft.
21O. DRILLING LOG Wwch tdditiouaf sheets if neecslan
FROM To DESCRIPTION (color, hardness, sattltoekl e, grain 51", ere.)
fL ft.
ft.
ft. It.
ft. Ft.
fit. ft.
ft. n.
ft. ft,
xL REMARKS
6ENTQNITE SEAL FROM 13.0 TO 18.0 FEET
22. Certification:
,SCe, " -5-aa 12-18-2014
Signature of Certified Well Contractor pate
fiv figning this form, I heretic• cerli,(c rlicrt Nye swil(s} ;teas (Were) Vaosrracrad in at-cardonce
rt7lh 15A NCIC 02C .6100 a" 15r1 AIC4C 02C.0200 Hell Conviruenan Slarulanlx tu:,jIlat fir
carp , ofthis record has been provltlerl to the melt ass7ner,
23. Site diagram or addilional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SURMITTALINSTUCTIONS
30,4
9. Total well depth below land surface:
P
(ft.) 24a. For All 1VeIls: Submit this fans ssithin 30 days of completion of well
Forruurhirle nulls IGr off deprltr Ifrliffe+'Val feeample- 3(u:200'atu+l26i4()0')
construction to the following:
10. Static water level below top of easing: NIA
(fit.) Division of Water Resources, information Processing Unit,
Ifnytler tenet is above casing, rise "t"
1617 Mail Service Center, Raleigh, NC 27699-1617
11. Borehole diameter: 8 (in.)
24b. For lniection Wells ONLY: In addition to sending I11c form to the address in
AUGER
24aabove, also submit a copy of this form within 34 clays of completion of well
I2.1Ye!] construetion method:
construction to the following:
ti.c. auger, rotay, cable. dircct push, etc.)
Division of Water Resources, Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY:
1636 Mttil Service Center, Raleigh, NC 27699-1636
13u. Yield (gpin) Mel bad of test:
24t. For Water Supply & Injeetion Wells:
Also submit one copy of this form within 30 days of completion of
13b. Disinfection type: Amount-
well construction to the county health department or the county where
constructed.
Form GW-1 Norih Cnrollna department of Environment
nad 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 7810-14-0154
PIEZOMETER NO CHATH-079-P102 INSTALLATION DATE 1211612014
LOCATION- NORTHING: 668,340.6' EASTINIG: 1,988,190.7' GROUND ELEV: 173.73'
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) LOCK TYPE/KEY CODE Dolphin 1600
' Preliminary -Final locatlonlelevation 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
VX2"X6")
GROUT
DEPTH TO TOP OF RISER
BENTONITE SEAL
= GROUND SURFACE
BENTONITE SEAL (Mln, 3 feet)
DEPTH TO TOP OF
GRANULAR MATERIAL
= 3.0 FEET
SCREEN
GRANULAR BACKFILL
CENTERING DEVICES INSTALLED
(APPROXIMATE DEPTHS)
= N/A
SUMP/CAP
Site Manager Review
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/ - 15.0 FEET
SOLID SECTION
= 5.0 FEET
DEPTH TOP OF
SCREEN SECTION
5.0 FEET
LENGTH OF SCREEN/
SLOTTED SECTION
10.0 FEET
DEPTH BOTTOM OF
SCREEN SECTION
15.0 FEET
9GTH OF SUMP & CAP
...0.2 FEET
039171
GINS�•� xRQA
n ih.•�rih/MkJ -.tip
STABILIZED WATER
LEVEL AFTER
DEVELOPMENT
NIA FEET
BELOW TOP OF
STICKUP
MEASURED ON
NIA DATE
BOTTOM OF PIEZOMETER
AMEC Well MslaAalrnn ftacord. Rev 0

WELL CONSTRUCTION RECORD
This form CUR he used fur single OF Tani Iiplc we)is
1. Well Contractor Information. -
Randy D. Hoffman
Well Contractor Name
3476
NC NY ell Contractor Cenification Nurnbcr
SAEDACCO
Company Nape
2. Well Construction Permit #:
Lirt all applicable well permits (i.e. Counn•, State, Vnriance. Injection, etc)
3. Well Use (checkwell use):
Water Supply Well:
[]Agricultural
130cothennal (Heating/Cooling Supply)
01nd ustrial/Comrncrcial
❑ Irrigation
Non -Water Supply Well:
❑Aquifer Recharge
[)Aquifer Storage and Recovery
[]Aquifer Test
❑Experimental Technology
❑0cothertnal (Closed Loop)
❑Geothermal 01catin glCoolins
❑Munic'lpallPuhlic
Olkesidential Water Supply (single)
C)Residential Water Supply (shared)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
C3Tracer
❑Clther fexnlain under k2I I
4. bate Well(s) Completed: 12/17/2014Well ID#'CHATH-079-P102
Sa, Well Location:
DUKE ENERGY - CAPE TEAR STEAM STATION
Facilitylgwner Name Facility Idle (if apPlicahle)
500 CP&L ROAD, MONCURE, NC 27559
Physical Address, City, and Zip
CHATHAM
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degreestminuteslseconds ar decimal degrees
01'well field, one lal/long is sufficient)
350 35' 10.93" N 790 02' 22.99"
6, Is (are) the well(s): OPermanent or ©•relltporaly
For Internal use ONLY:
Li, W&TER
btiNVS
FROM
ro-
DESCRIP110LN
n.
fl.
-
i5, i1LrrCR C_ v4 ` G (far mufti-exted wells OR [JNE R l)f plitablej
FROM
I Ili _
DIAMETER
HFICKNEss
0.0 ft.
5.0 rt-
2 w-
SCH 40
_N1ATERM,
PVC
Ili, JNIN R
C i0 C XVILIBILA42_tmfttbtrm&J
closed -I ann i
FROM
TO
DIX&NtET'ER
TInChNEss
,M %IrRIAL
It. ft,
fa ft.
IT, S+CII�
FROM
to I
DIANIEMR
sLOTstLE
Irrttc+Etitss
NIn rERIAt.
5.0 re.
15.0 ft
2 t"-
0.01
SCH 40
PVC
ft.
ft..
-
IIL G(I,OtT
FROM
TO
MATERIAL
EMPLACPMENT;NEITIOD&ANIOUNT
ft.
ft,
ft.
ft.
R.
ft.
99.S\D Gtx_i%-VL r'AC1►
(if [ItAht4) —
FR0�1
- TO
MATERIAL
Es1rLACFatE;VT':k1ETllOn
.0 rr
3.07
7
15.0 rt•
Quartz Sand
fL
ft,
20. plill. ANC
I�OG (;attach adnnt ditional srietra If ae)
FROM
TO
DESCRIPTION lcolvr, harlln"i. sunfruek s c, Drain size, ere.
Ft.
ft.
ft.
ft.
ft,
ft.
n.
ft.
ft•
fL
ft.
ft.
ft.
rt.
-
2r.RIE-rMAR1
S -
BENTONITE SEAT- FROM 0.0 TO 3.0 FEET
22, Certificatiorn-;
Rr rT�KiQ44
W
signature orecrlifaed Well Contractor
7. Is this a repair to an existing well: ❑Yes or EINo
If ilds is a repair, fill ani konivr, twit v.orestraction information and erepluln the nature nj'tdw
repair under 921 reararks section oe on lira back of fiefs form.
S. Number of welds constructed: 1
For awhiple itleetioa or nor -water suppiv Ivells ONLY sviih the sanee construction. yore can
submit arse forth.
9. Total well depth below land surface: 15.0 (ft.)
For ataltiple wells list all depths if do)ferern (esmnple- 3�1a„tfl1 ° ord7tt�.1llF1')
l0. Static water level belotV top of casing: NIA 00
!f wetter level is ahow rasing, use " - "
I I. Borehole diameter: 8 (in,)
12. Well construction method: AUGER
().c. auger, rotary, cable, direct push. cic.)
12-17-2014
vale
r signing this furor. 1lrcrelrs cerh
A, that the well(s) wat (here) calufmclud in accordanve
with 15A NC.4C 02C.0100 nr 15A NCRC 02C .Worl Well Cvnsrrtrcriarr Stnrldnrels foal that a
Capl' of this rr'eord has been prow&d to the well on'}rer.
23. Site diagram or additional well details:
You may use the hack of this page to provide additional well site details or well
construction details. You may also attach additional pages ifnecessary.
SUB+ I'I"FAI, INSTUCT1ONS
24a. For All Wells: Submit this form within 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
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 39 days of completion of ~,yell
construction to the following:
Division of Water Resources, Underground Injection Control Program,
FOR WA'rER SUPPLY WELLS ONLY: 1636 M2il Service Center, Raleigh, NC 27699.1636
24c. For Water Su 1 & Injection Wells:
13a.1'ield ([gym) Method of text: Also submit one copy of (his form within 30 days ofcomplelion of
13h. DWrifeetion type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Deportosent of Environment and Nolu ml Resources - Division of Waler Resources Revised Aogtw 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-079-P103 INSTALLATION DATE 12/1812014
LOCATION' NORTHING: 669,272.4' EASTiNG: 1,988,713.5' GROUND ELEV: 193.93'
AMEC FIELD REPRESENTATIVE D. Atkinson DRILLERI CONTRACTOR Mid -Atlantic Dril
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 TYPEIKEY CODE Dolphin 1600
' Preliminary -Final locationfelevation to be determined by As -Built Survey
Reference paint 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
r
NOTE: NOT TO SCALE, ALL DEPTHS RECORDED
ARE RELATIVE TO EXISTING GROUND SURFACE
AT TIME OF INSTALLATION
DEPTH TO TOP OF RISER
BENTONITE SEAL
- 13.0 FEET
BENTONITE SEAL (Min. 3 feet)
DEPTH TO TOP OF
GRANULAR MATERIAL
= 18.0 FEET
SCREEN
GRANULAR BACKFILL
CENTERING DEVICES INSTALLED
(APPROXIMATE DEPTHS)
- N/A
-t30.0
LENGTH OF RISER/
SOLID SECTION
- 20.0 FEET
DEPTH TOP OF
SCREEN SECTION
- 20.0 FEET
LENGTH OF SCREEN{
SLOTTED SECTION
- 10.0 FEET
IV
DEPTH BOTTOM OF
SCREEN SECTION
FEET
SUMP{CAP
rrH OF SUMP & CAP
g•; 0:-j FEET
GROUND
TOTAL DEPTH
OF PIEZOMETER
30.4 FEET
STABILIZED WATER
LEVEL AFTER
DEVELOPMENT
N/A FEET
BELOW TOP OF
STICKUP
MEASURED ON
- N/A DATE
--
039173 BOTTOM OF PIEZOMETER
f
•GINS ����qameo
{� �j!!!1lIIIIA;tii
Site Manager Review l , 9`7',G{%j% Date.
AMEC Well lnstafttmn Reeved. Rev 0

WELL CONSTRUCTION RECORD
Tlrs form can be used for single or sntslliple wells
L Well Contractor Information:
William M, Wiggins
Well Contr-actor Name
3470
NC Well C#1atrYCilY1t6&t 'VS'45F6MbCr 790 02' 16.66"
MID -ATLANTIC DRILLING, INC.
Company Vance
2. Well Construction Permit 9;
List all applicahta u,01 permits (i.e. cauttor, Star-,, f 4riance. Injrc000. ote l
3. Well Ilse (cheek well use);
Water Supply Well:
O Agricultural
ONfunicipal/publis
DGeothermal (licatinglCooling Supply) 014cstdential Water Supply (single)
'21ndustria(fCommerciai Mesidentiaal Wa(crSupply (shared)
Non -Water Supply Yell.-
emonitoring
13Aquiter Recharge
C)GroundAuter Remediation
0AqulferStorage and Recover v
CISalinityBarrier
ClAqulfer Test
ClStonnwatcr Drainage
OExperimcnlal Technology
[]Subsidence Control
©Gcotherroal (Closed Loop)
❑'Tracer
[]Geothermal (Heating/Cooling Retuni)
❑Othcr (t:xnlain under 421 P
4. Date Well(s) Completed: 12/18/2014 Well ID4 CHATH-079-P1 03
5a. Well Location:
DUKE ENERGY - CAFE FEAR STEAM STATION
Facility/Owner Name Faciliry (00 (if npplieable)
500 CP&L ROAD, MONCURE, NC 27559
Physical Address, City, and Zip
CHATHAM
Comity Parcel Identification No. (PINT)
5b- Latitude and Longitude in degrees/minuteVsecnnds or decimal degrees:
lif-,veil field, one latllong is sufficient)
1xRo Orr, 71i I r" 700 n,), 1 R nan
N
6. Is (are) the ivell(s): filPermanent or t]'I'emporary
W
7. Is this a repair, to an existing well: Oyes or EINQu
If ibis rs a repair. fill ow kno,rtr well construction m6irmatim, and explain the nature of the
mpair uncles -21 remarks section or on rile hack of tltrs farm.
8. Number of wells constructed! 1
Vorninhiple rnleviton or rum-rvater supply wells ONLF I. the same constructilod, yotr can
submitonefrmr.
9. Total well deptb helow land surface: 3Q•4
i•ur multtple "'ells list till depths j dffereol reora 1ple- 3@209' and 2 ii l qI1")
10. Static water level below top of casing: NIA tri i
1fhater level is nhow casing, use -= ,
It. Borehole diameter: 8 (in.)
12. Well construction method: AUGER
0 c. auger, rotary, cable, direct pusly etc.)
For lutemal Use ONLY.
I4.'WATER ZONES
FROM TO I nVSCRTP'ITON
ft I ft
ft. I ft
1S. OUTER CASING foruralti-cased 34C1I3 QR LINER 1f 0. litabir
f
tf
DIANIrr£lt THICKNESS NrarERL%L f' 0 rr. 2 i,, SCH 40 PVC
16. INNER CASING OR TiI8111tC, eother®al closed-loo
FROM TO nLLftETER T7fICK,NS.S I MATERLAL
ft. ft. in
fr. ft. In,
17. SCREEN
FRUM TO DIAA1tCTFlt SLOTSIxE MCKN-t:5S THATERU
20.0 ft- 30,0 Ir. 2 In. 0.01 SCH 40 PVC
ft. I ft. in.
I& GROUT
FROM TO At.kTER1AL EMP ACLIvf iT.VETROD & AhtOLN-r
0.0 ft' 13.0 ft- Cement Slurry
ft, fr.
ft. ft.
19, SANDIGRAV$L PACK UP licable)
FROM TO ZfhTER1AL F.1tYt.ACIM'IrENT511T1100
18.0 fr. 30A fr- (Quartz Sand
ft. m
20. DRILLING LOG utgtch additional sheets ifnecessary)
17i0 r - TO D&S CRIP'f1UN color, hardness. soiUro L h e, rode sue, ncj
rr ft.
f[ ft.
ft. ft
ft. rG
(t. ft.
rt. ft.
r,, ft.
21. REMARKS
BENTONITE SEAL FROM 13.0 TO 18.0 FEET
22. Certification:
c
Sipptu Lure of Certified Well Contractor Date
By signing this form, I hercbt• certifv iluit the nellfs) was llverul consrrncled io accardan e
tr rth 11A NCAC 0R' .0100 or 1 SA NC AC 02{' ,02UO Welf C'omerricimn Standards and elan a
cop), of this record has beers provided to tier %�efi orener.
23. Sire diagram or additi Gila] '6vell details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUHrMMAL iNSTUCTION+fS
24a. For All Wells: 'Submit this form within 30 days of completion of -,veil
construction to the followng:
Division utlVater Reaaurcer, Tttformatlon Processiag Vnit,
1617 Nfail Service Center, Raleigh, NC 27699-1617
24b. For Injecton W Its ONLY: 1n addition to sending the form to the address in
241 above, also submit a copy of this form within 30 da} s of completion of weld
construction to the following.
Division of Water Resources, Underground Injection Control Program,
FOR WATER SLTPPLY WELL 5 ONLY: 1636 flail Service Center, Raleigh, NC 27699-1636
13n. yield (gpm) 1letbod of test 24c. For Water Supply & In ection Wells:
Also submit one copy of this form within 30 days of completion of
13h. �isinfcction type:Amouut. well con ttxtetian to the county health department of the county -where
constructed_
Form OW-1 North Carolina Department of Envtrontneut and Natural Resources - Division of Watet 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-079-P104 INSTALLATION DATE 12/1712014
LOCATION* NORTHING: 670,440.1' FASTING: 1,987,674.3' GROUND ELEV: 193.82'
AMEC FIELD REPRESENTATIVE D. Atkinson DRILLER/ CONTRACTOR Mid -Atlantic Drilli
GRANULAR BACKFILL MATERIAL GP #2 Quartz Sand DRILLING TECHNIQUE Hollow Stem Aug
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 16DO
` Preliminary -Final Incationlelevation 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. I'BELOW GRADE)
CONCRETE PAC!
(2'X2'X6")
GROUT
NOTE: NOT TO SCALE, ALL DEPTHS RECORDED
ARE RELATIVE TO EXISTING GROUND SURFACE
AT TIME OF INSTALLATION
DEPTH TO TOP OF RISER
BENTONITE SEAL
= 13.0 FEET
BENTONITE SEAL (Min. 3 feet)
DEPTH TO TOP OF
GRANULAR MATERIAL
- 18.0 FEET
SCREEN
GRANULAR BACKFILL
CENTERING DEVICES INSTALLED
(APPROXIMATE DEPTHS)
- N/A
c+rt.rj
LENGTH OF RISER/
SOLID SECTION
= 20.0 FEET
DEPTH TOP OF
SCREEN SECTION
- 20.0 FEET
LENGTH OF SCREEN/
SLOTTED SECTION
= 10.0 FEET
r
DEPTH BOTTOM OF
SCREEN SECTION
= 30.0 FEET
amec�
GROUND
TOTAL DEPTH
OF PIEZOMETER
30.4 FEET
STABILIZED WATER
LEVEL AFTER
DEVELOPMENT
NIA FEET
BELOW TOP OF
STICKUP
MEASURED ON
N/A DATE
GTH OF SUMP &CAP
SUMP/CAP,
'#).4 FEET
SEAL
- BOTTOM OF PIEZOMETER
INS: R
f+AYDFORD �100
��
DiilII
Site Manager Review
AMEC Well InstaNuuan Reaerd. Rev

WELL CONSTRUCTION RECORD
This farm aim he used for smgle tar multiple wells
1, Well Contractor Infortuation:
William M. Wiggins
Well Contractor Name
3470
NC Well Contractor Cortific.alion Number
MID -ATLANTIC DRILLING, INC,
Company f ainc
2. Well Construction Permit #:
Litt all applicable s.ell permhx (i.e. Catrna;v, Stare, i�ariance, Infection, Ile)
3. Well Use (check well use):
Water Supply
❑Agricultural
ClGeothetmal (Heating/Cooling Supply)
❑ Indust riaVComrnercial
Non -Water Supply Well:
©Iytonitoring
Injection Well;
I:MAquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
OExperimental Technology
0Gcothermal (Closed Lonp)
❑Geothermal (HealingtCooliniz
❑MunicipaMblic
DResidential Water Supply (single)
❑Residential Water Supply (shared)
OGround,,,,wer Remediation
USalinny Barrier
E]Stonn'Watcr Drainage
❑Subsidence Control
GTracer
❑other (explain under 421
4. Date Well(s) Completed. 12/17/2014well M4 CHATH-079-P104
5a. well Lucation:
DUKE ENERGY -CAPE FF_ R STEAM STATI ON
Paths 10wrterName Facility[DO (if applicable)
500 CP&L ROAD, MONCURE, NC 27559
Physical Address. City, and Zip
CHATHAM
County Parcel ldentiFieat on No. (PIN I
For Internal Use ONLY-
14. WATER ZONEs
FROM
TO
DESCICIYITOV
fL
ft
ft.
ft.
ti. OUTER CAbSrNG for
mt1iA-c;vaIsEetd'1wells) OR applicable)
5i5f
FRLAL
fFRf4MjT
g. 20.0 fL
2 iar. 5CH 40 PVC
16. INNER CASING OR
TUBING eothermal
closed-lootil
FROM
To
DIAMETER 1
TIIICKNE.SS
MIATERLIL
ft,
ft.
in.
ft.
FL
in.
17. SCREEN
FROM TO
t)IAw3?-i R
I SLOT51""LE
I THICENESS
I A1ATERIAL
20.0 it, 30.0 f'
2 ra
1 0.01
SCH 40
PVC
ft. rt,
in.
Is. GROUT
FROM TO
MATERIAL
ERIPI.A CEMENT NIE1HOD & A.110VN r
rr" rt,
Fit. ft
I9. SANDIGRAV£L PACT{
if a licahle
FROp1
T MATERIAL
EkrpI ACEhfEXTMF'TRO4
18.0
30.0 rr.
Quartz Sated
ft.
ft.
20. DRILLING
LOG(attach aadditlonalsheco irnecess
FROM
TO
DFSCRIPTIOV color, hardness, saiVraek type, gifto site, et c.I
fL
(L
fL
ft.
fr.
ft.
ff.
ft.
n.
Ft,
fr.
fL
it.
ft.
21. REMARKS
BENTONITE SEAL FROM 13.0 TO 18.0 FEET
Sh. Latitude and Longitude in degreeslntinuteslseconds or decimal degrees: 22 Certification:
lit'vvoU field, one lat-long is sufficient) q�t
350 35J' 31.69a 17 90 02a 29.26rn - c
l'i&M,. of Crrtified 1Ve Co?a racaor pate
6. Is [are) the tivell(s): dPermnuent or OTetnpurary BY signayty Arta form, I lervi i, certify that the aell(s) ryas (srerel constructed in accomance
with 15A NC'AC02f .WIN) or 15,1 NCA(' d?f' ,0200 )VeII Consrrurrien Standards and that a
7. Is Oka repair to an existing well: ❑Yes or ONo copy of Arts record has hven provided to the well owner.
If this r:r a repair, foil arat knoirn well construction Inforaaorion and explain the nature of she
repair under -TI remarks secNora nr aua she bask gfIlir_e farm. 23. Site diagram or additional well details:
8. Number of wells constructed: 1
l-or rrmistple Injection or non-w•atersupply wells O,ti1.1' o rth die snare conssrtsctinrr. ),ran can
srrhrnlr o e form,
9. Total well depth below land surface; 30.4 (ft.)
Par rnrrhiple malts Ito all depths f differeat (exaualalc- J 100 `and 2 yr 100')
In. Static water level below top Greasing: NIA
1f H-aler level is above cershrk. Itse "
11. Borehole diatneter,- 8 (in.)
12. Well copstruction method: AUGER
(i.e. auger, rotary, cable, disca push, etc I
You may use the back of this page to providc additional well site details or well
construction details You may also attach additional pages if necessay.
SUBMITTAL INSTUCTIONS
24a. For All Wells- Submit this form within 30 days of completion of wall
construction to the following:
Dlivisiov of Wager Resources, information Processing Unit,
1617 Mail Service Center, Raleigh, NC 276994617
24h. For InItCtitin Wells ONLY: In addition to sending the farts to the address in
24aabove. also subinit a copy of this form within 30 days of completion of well
construction to the fallowing:
Bivtision of Wafter Resources, Underground Injection Control Program,
FOR WATER SLTPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13m. Yield (gpm) Method of test, 24t• For Water Supply & Injeetion Wells:.
Also submit one copy of this form within 30 bays of completion of
13b. Disinfection type: Amount: %NA construction to the county laealdi dcpartrnertt of the county where
constructed.
Form GW-1 North Carolina Departruetal ofEnvirormrcnt aid Natural Resources -Division of WatcrResources Revised August 2D13

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-079-P10S INSTALLATION GATE 12/17/2014
LOCATION" NORTHING: 670,515.3' EASTING: 1,987,699.1' GROUND ELEV: 173.40'
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 TYPEXEY CODE D91phin 1600
' Prelim nary -Final location/elevation to be determined by As -Built Survey
" Reference paint 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 RIS
BENTONITE SEAL —�
= GROUND SURFACE
BENTONITE SEAL (Min. 3 feet)
DEPTH TO TOP OF
GRANULAR MATERIAL
3.0 FEET
SCREEN
GRANULAR BACKFILL
CENTERING DEVICES INSTALLED
(APPROXIMATE DEPTHS)
= N/A
ti
NOTE: NOT TO SCALE, ALL DEPTHS RECORDED
ARE RELATIVE TO EXISTING GROUND SURFACE
AT TIME OF INSTALLATION
LENGTH OF RISER/
SOLID SECTION
5.0 FEET
DEPTH TOP OF
SCREEN SECTION
5.0 FEET
LENGTH OF SCREEN/
SLOTTED SECTION
10.0 FEET
DEPTH BOTTOM OF
SCREEN SECTION
15.0 FEET
d?€4,TH OF SUMP & CAP
FEET
SUMP/GAPJ
GROUND
TOTAL DEPTH
OF PIEZOMETER
15.0 FEET
STABILIZED WATER
LEVEL AFTER
DEVELOPMENT
N/A FEET
BELOW TOP OF
STICKUP
MEASURED ON
N/A DATE
SEAL BOTTOM OF PIEZOMETER
ameO•, Cr.
. 11 Fof `
Site Manager Review IC SM Date:
AMEC waft Insrarlaflon Record. Rev 0

WELL CONSTRUCTION RECORD
This four can be used for single or multiple wells
1. Well Contractor Information:
Randy D, Hoffman
Well Contractor Name
3475
NC Well Contractor Certification Number
SAEDACCO
Company Namc
2. Well Construction Permit #:
UVI all applfcahlr swit pormils (i.e. C'oun(y, State, irarlanee, ltrjecfion, etc.)
3, Well Use (check well use):
Water Supply Well.
FlAgricultural
❑Geothermal (HeatinglCooling Supply)
❑ In dustrialfCommercial
DMu nisipal/Public
OResidential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Weil:
0 felon I tonng
❑ Rec overt'
Injection Well:
❑Aquifer Recharge
❑Groundwater Remediation
❑Aquifer Storage and Rccovery
❑Salinity Barrier
❑Aquifer Test
❑Stonnwater Drainage
❑Experimental Technology
❑Subsidence Control
❑Gcothermal (Closed Loop)
❑Tracer
❑Geothermal (Ilealing/Cooling Rehire)
[]Other (exnlain under #21 Remarks)
4. hate Wells) Completed: 12/17/2014 Well ID# CHATH-079-P105
5a. Well Location:
PURE ENERGY -GAPE FEAR STEAM STATION
Facility/Owner Name Facility ID# (ifappIicablc)
500 CP&L ROAD, MONCURE, NC 27559
Pllysicat Address, City. and Zip
CHATHAM
County
parcel Ide nt ificat ion No. l PIN )
5b. Latitude and Longitude In degrees/minutes/seconds or decimal degree
(if well fietd, one Iat1tong is soRicienl)
350 35' 32,44" N 79" 02' 28.96"
r
Internal Use ONLY_
la, WATI;RZOINES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft,
15.41L.-fERt'
as -pr> l'M �ORUNIFR •
FROM TO
DtA.ME7En
TTIICKNESS
MATERIAL
0.0 n 5.0 u.
2 In.
SCH 40
PVC
IC INNER
CASING OR'f�TL�ILS'G
ermef cloud -Iv I
FROM
'to
DIA-81IXER
TuICKNEss
MATERIAL
ft.
ft.
tn.
ft.
ft.
lu.
17. SIC6LM
MOM TO DIAMP3EN
SLOTSIM
THICIHNESS
AIAT'ER1AL
5.0 ft- 15.0 B 2 tn.
0.01
SCH 40
PVC
R. ft. in..
111, GROUr
FROM
To
MATERIAL
EMPLACEMENT NIETHOn & A IOUNI
ft,
ft.
ft.
ft.
ft.
ft.
19, S'L? D GRAB
LL PACK
Itf ■ licAble)
FROM
TO
MATERIAL
EMPLACEAI£:NT METTIOD
3.0 ft•
15.0 f[•
Quartz Sand
ft.
tY.
20. 0RILLING
i OG attach adtlltiottal shire tr ff )
FROM
TO
DESCRIPTION color, hardness, soiNraek tv, p c, in sue, um
fl.
ft.
ft.
ft.
n.
ff.
It.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
2 L. R"11 a_RISS
BENTONITE SEAL FROM 0.0 TO 3.0 FEET
s' 22, Certification:
W
' 41 4 q°#- 4- 12-17-2014
Signature of Certified Well Contractor Date
6. Is (are) the well(s): 211permanent or DTeinporary By signing dris faun, l herebT cerf�- Ilia) the uxll(r) was (were) conslracred in accardanvi.
101h 15d NCdC 02C.0100 or 15A NC,AC tl fC .0200 I'Velf Construction Standards and tint/ a
7. Is this a repair to an existing well: OYes or ®No core afrlrfs record has frees praridecfra rlre ss¢ff ortner.
Ifthis is a repair, Jiff nut ktmn n wall Construction Information wxl erplaln rhr mania gf0te
"Pairlaatler #21 remarks sw iori or on the hack ofthisfmar. 23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or Well
8. Number of wells constructed: construction details. You may also attach additional pages if necessary.
For maillple tnjection or nwr•xoter.suppts, sells ONLl' ivifh the Rante ronstruesion, srou can
slibtult am firrrri. SUBMITTAL INSTUC'I'IDNS
9, Total well depth below land surface: 15.0
For oruhlpk w elkv list all rlepikV if,lijfcretrt (eralttple- 3t t; 2trp' and. (qt W')
10. Static water level below top of casing: NIA
If stutur 1t!wl is abase casing, arse
24a. For All Wells: Submit this form within 30 days of completion of well
constniction to the following:
(ft.) Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699.1617
11. Borehole diameter: (in.) 24b. For Iniection Wells ONLY: In addition to sending lire form to the address in
A��E� 24aabove, also submit a copy of this form within 30 days of completion of well
12. Well construction method; construction to tale following:
(i,c, auger, rotary, cabtc, direct push, ere.)
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WILLS ONLY: 163E 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 clays of completion of
13b. Disinfection type: Amount: Well construction to the county health department of the county where
constTuctcd.
Form GW-I !North Carolina Department of Environment and Natural Resources - Division nt- Water Resources Revised August 2013