GW1--01584_Well Construction - GW1_20240308

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: . tl
Oliver Pederson FR MATER TONES.= DESCRIPTION
Well Contractor Nam! ft f` No Water in boring
• 4481-A ft. ft. 1- ' .
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER fif ap licable) •
•• _
FROM TO DIAMETER '.THICKNESS MATERIAL
Cascade Drilling ft. ft. . ; in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM . TO DIAMETER THICKNESS . MATERIAL
2.Well Construction Permit#: . . . . ft• D. in.
List all applicable well permits(i.e.County,State,Variance,injection,etc) ..
ft. ft. , in.
3.Well Use(check well use): 17.SCREEN
TFROM Supply Well: FROM' TO DIAMETER 1 SLOT SIZE THICKNESS • MATERIAL
DAgricultural ❑Municipal/Public •
ft. ft. tn.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑IndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
FROIIi TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation -- - --- .-.0 ft. 90' ft-
Non-Water Supply Well: •
ft. .ft.
•
❑Monitoring .❑Recovery •
Injection Well: ft. ft.
.
• ❑Aquifer Recharge - - ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) -
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage - '
ft. ft.
❑Experimental Technology ❑Subsidence Control `
20.DRILLING LOG(attach additional sheets if necessary),' '
OGeothermal(Closed Loop) ❑Tracer .FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) XOther(explain under#21 Remarks) ft. ft. I ' .
4.Date Well(s)Completed:2-16-2024Well ID# EXT-4 .. ft. ft. No Samples taken
ft. it Drilled through a-concrete
5a.Well Location: It. ft. t'.'.: '^-•' -
pillar �•-t � ‘\ � •-
Duke Energy . . ft. ft. ° ,•--`':..r is t V�%.:d `i
Facility/Owner Name Facility ID#(if applicable) ft. ft. MA
1700 Dunnaway.Road, Semora, NC 27343 ft. ft.
Physical Address,City;and Zip Inn :;=.:z,il ;?, i•
21.REMARKS i.'t,
Person .. . - extensometer U-0r:�•`;,t
County . Parcel Identification No.(PIN) '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one.lat/long is sufficient)
. 36°28'46" N . . 79°3'53." w 2-16-2024.
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or_ ❑Telllporary-. _ - --=.'By'signing this form,-!hereby certj that the-well(s)was(were)constructed in accordance - - -
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well:. fYes or XNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. .23.Site diagram or additional well details:
You may use the back of this page,to provide additional well site details or well •
S.Number of wells constructed: 1 cohsttilction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submitoneform.. SUBMITTAL ALINSTUCTIONS •
9.Total well depth below land surface: .90' (ft.) 24a. For All Wells: Submit this!form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following: 1
10.Static water level below top of casing: NA (ft.) Division of Water Resources,Information Processing Unit, .
If wilier level is above casing,use"+" ' 1617 Mail Service Cienter,Raleigh,NC 27699-1617
II
11.Borehole diameter: 7" (in.) 24b.For Infection Wells ONLY:1 In addition t6 sending the form to the address in
24a above, also submit a copy of'this form within 30 days of completion of well,
12.Well construction method: Sonic Drilling •construction to the following:
er,rota
(i.e.
au ,g ry,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(gpm) 24c.For Water Supply&Injection Wells:
m 13a.Yield Method of test: -
. Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. .
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division Of Water Resources Revised August 2013