GW1--05649_Well Construction - GW1_20230831

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I t
Nicholas Moreno `14rWATERZONES.. ,1
We1lContractor Name FROM TO DESCRIPTION
ft. ft.
4209-A
ft. I ft. I .
NC Well Contractor Certification Number 15.OUTER CASING(far"multi-eased':wells)OR LINER(fop'"&able)'
Keller Industrial FROM TO DIAMETER: THICKNESS 1 MATERIAL
ft. ft. I in.
CompanyName
`16.INNER,CASING,OR-TUBING(geothermal closed loop)`:,''
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 27 ft 4 in' Sch 40 Fvc
3.Well Use(check well use): ft. ft. in
Water Supply Well:
47c:SCREEN, . ..:,r, _.,:. (. ,,.. ._.,...Z' ..1.,„:,-,, ,,,, 7x,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public 27 ft 47 ft 4 in'' 20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft.' ft in.
Industrial/Commercial E3Residential Water Supply(shared) t 1
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
i'
Monitoring Recovery ft. ft.
Injection Well: ft. l ft.
Aquifer Recharge °Groundwater Remediation
Aquifer Storage and Recovery (q Salini Barrier ..19.SAND/GRAVEL PACK(if applicable)
q g tY FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStorraeaaterDraittage 0 ft. 47 ft 4ASend e i' Tremen
Experimental Technology EDSubsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer ,i.20.DRILLING LOG(attach additionafsheets if necessary)='s '. .r �. '
FROM I TO DESCRIPTION(color,hardness,soil/rock
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
soil/rock type,grain size,etc.)
t ft• 5 it. Dade grey ash
4.Date Well(s)Completed:7-24-23 Well ID#DW 1-16 5 ft. to ft Redish brown sandy clay
5a.Well Location: tU ft' 45 ft- Dark grey ash
Duke Energy 45 fL 4T it Native
Facility/Owner Name Facility ID#(if applicable) ft. ft. r• -,�
8320 NC 150, Sherrills Ford, 28673 ft. ft jjj
Physical Address,City,and Zip Ct.
I CL I A U G 3 1 2@ 73 F ,.
s21:REMARKS,,L_ Y
Catawba . ,
County Parcel Identification No.(PIN) If1farw,ast.^a1 PfC•419 i.Itt
5b.Latitude and longitude in degrees/Minutes/seconds or decimal degrees: ,
(if well field,one lat/long is sufficient) 2 .Certiticatio • ,
35.61599 N 80.97861 W
6.Is(are)the well(s)ijPermanent or IETemporary l mtme 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: °Yes or ONo 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: 47 (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(4)100) construction to the following: 1 '
14.9
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: 8 (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:
(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&Iniection 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