NC0004774_Duke Buck Steam Test Well GW-1 Form_20180112

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
t fr-ESV­� " k —
Company Name
2. Well Construction Permit h' �lr A-1
List all applicable well permits (i.e. County, State, Variance, Injection, etc)
3. Well,Vse (check well use):
Water Supply Well:
DAgricultural
oGeothermal (Heating/Cooling Supply)
Dindustrial/Commercial
El Irrigation
Non -Water Supply Well:
0 Aquifer Recharge
DAquifer Storage and Recovery
El Aquifer Test
OExperimental Technology
DGeothermal (Closed Loop)
DGeothermal (Heating/Cooling
OMunicipal/Flublic
OResidential Water Supply (single)
oResidential Water Supply (shared)
oGroundwater Remediation
• Salinity Barrier
• Stormwater Drainage
ElSubsidence Control
OTracer
00ther (explain under #21
4. Date Well(s) Completed: —M ('g well
5a. Well Location:
Facility/Owner Name
Facility ID# (if applicable)
N' 2_ '0D4 k'
Physical Address, City, and Zip
001' 011 - <
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
5 N W
6. Is (are) the well(s): Xermanent or OTemporary
7. Is this a repair to an existing well: CYes or 0
1�
Ifthis is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back ofthis form.
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface:
70p (ft.)
For multiple wells list all depths iftlifferent (example- 3@200' and 2@100')
10. Static water level below top of casing: Z (ft.)
Ifwater level is above casing, use
11. Borehole diameter: Cp (in.)
12. Well construction method: d4
(i.e. auger, rotary, cable, direct push, etc.)
IFor Internal Use ONLY:
22. Certification:
Sig0&urd`ofCertified,W1afI Contractor Date
By signing this form, I hereby certify' 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
copy of this record has been provided to the well owner.
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 additional pages if necessary.
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 Injection 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 following:
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.
13a. Yield (Bpm) 11 Method of test: Also submit one copy of this form within 30 days of completion of
13b. Disinfectiontype: Amount:
well construction to the county health department of the county where
constructed.
Form GW -1 North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013
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DESCRIPTION (color, hardness, soff/rock type, grain sin, etc,)
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22. Certification:
Sig0&urd`ofCertified,W1afI Contractor Date
By signing this form, I hereby certify' 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
copy of this record has been provided to the well owner.
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 additional pages if necessary.
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 Injection 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 following:
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.
13a. Yield (Bpm) 11 Method of test: Also submit one copy of this form within 30 days of completion of
13b. Disinfectiontype: Amount:
well construction to the county health department of the county where
constructed.
Form GW -1 North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013