GW1--03668_Well Construction - GW1_20230530

t?rint form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Nicholas Moreno 14 WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. fL j
4209-A
fL ft.
NC Well Contractor Certification Number 15..OUTER.CASING for"multi-cased wells OR LINER If a licable ,
Keller Industrial Inc FROM To DIAMETER THICKNESS MATERIAL
fL it. in.
Company Name =16ANNER.CASING ORTUBING'"eothermal closed-loo
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 fL 30 fL 2 In Sch 40 we
3.Well Use(check well use): ft. ft. In.
17.SCREEN-.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
Agricultural OMunicipa"ublic 30 ft. 40 ft. 2 Iu. 20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft, in.
F Industrial/Commercial OResidential Water Supply(shared) 18:GROUT.,—:_--
1hritzation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 30 ft. Bentonite Pellets Tremmle
Monitoring DRecovery ft. ft.
Injection Well:
fL fL
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a 'licable
Aquifer Storage and Recovery Salinity Barrier
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStotmwater Drainage 30 ft. 40 ft. to Sand Tremmis,
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) IOTracer 20.DRILLING LOG(attack additional sheets if necessary),
Geothermal(Heating/Cooling Retum) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilfrock type rain Size,etc.
0 ft. 8 It. Tan Clay
4.Date Well(s)Completed:4-24-23 Well ID#OW-1 6 ft. 32 iL Sand Ah
5a.Well Location: 32 ft. 37 fL Ash
Duke Energy Belews Creek 37 fr. 38 ft- Sandy Ash
Facility/Owner Name Facility ID#(if applicable) 39 ft. 40 % Native Ground
3191 Pine Hall Road,Walnut Cove, NC 27052 ft. ft. MAY
Physical Address,City,and Zip It. ft.
Stokes zi_REMARIrs;'
County Parcel identification No.(PRE
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Held,one lat/long is sufficient) 22.Certification:
36.28549 N 80.07856 W
6.Is(are)the well(s)12Permanent or OTemporary fflinature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or EJNo with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 40 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following'
10.Static water level below to casin •21.7
p of g. (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,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
13a.Yield(gpm) Method of test: 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016