GW1--03681_Well Construction - GW1_20230530

i-"r -Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Nicholas Moreno i 14:WATER ZONEs .
Well Contractor Name FROM TO I DESCRIPTION
L
4209-A ft. f
ft. ft.
NC Well Contractor Certification Number 15.'OUTER CASING for"uulti-cas'ed'wdls OR LINER'ifs""lic8ble :'-
Keller Industrial Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. fL in.
Company Name
16:INNER CASING,ORTUBING`(Oot6ermal,closed-lo6p)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc.) 0 fL 10 ft, 6 In. Sch 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: :.:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Mrmicipal/Public 10 fL 40 tL 6 in. 20 Sch40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) fL ft.
Industrial/Commercial []Residential Water Supply(shared)
A&GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery fL fL
Injection Well:
ft
Aquifer Recharge Groundwater Remediation
19.'SAND/D/GRAVEL-PAC K.if a' licalile -
Aquifer Storage and Recovery Salinity Barrier FROM TO MATE IAL EMPLACEMENT METHOD,
Aquifer Test E2&ormwater Drainage o fL 4o fL 1A Sand Tremme
Experimental Technology ElSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer '10.DRILLING LOG attach additional sheets if neces"sa
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soillrock type,grain size,etc.
p it. 5 It- Tan Clay
4.Date Wells Completed:4-26-23 Well ID#DW-5 5 ft' 14 ft Sand Clay
O P Y Y
5a.Well Location: 74 ft. 88 ft. Ash
Duke Energy Befews Creek 36 It, 40 ft, Sand
Facility/Owner Name Facility ID#(if applicable) ft. tL Ut-�,;�{
3191 Pine Hall Road,Walnut Cove, NC 27052 ft. ft
Physical Address,City,and Zip ft. It.
Stokes :21.'REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 22.Certification'
36.28549 N 80.07856 W
6.Is(are)the well(s)OPermanent or OTemporary gnamre of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EJNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out(mown 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:
5
10.Static water level below top of casing:29. (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: 12 (in.) 24b.For Injection 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:
(Le.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&Injection 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