GW1--05658_Well Construction - GW1_20230831

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. 1 Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: •
rI
Nicholas Moreno '14.WATER ZONES _ '
Well Contractor Name FROM TO DESCRIPTION
ft. ft. I
4209-A
ft. ft. f
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'wells)`OR LINER(If ap licable)
Keller Industrial FROM TO DIAMETER THICKNESS 1 MATERIAL
ft ft. in.
CompanyNatne 1.16.-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, 16 ft• 4 in. Sch 40 vvc
3.Well Use(check well use): ft' ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 16 ft• 36 ft• 4 1n. .20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.:'
Industrial/Commercial E3Residential Water Supply(shared) r8.GROUT :-
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery . ft. rt.
Injection Well:
ft. ft. I 1
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable) '
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DiStormwaterDrainage 0 ft• 3,5 ft. ?RSand; Trenw/e
Experimental Technology 0ISubsidence Control ft. ft.
Geothermal(Closed Loop) DITracer 20.DRILLING LOG.(attach additional sheets if necessary) " -
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO
A ft• 5 ft• Bafic greyDESCRIPTION ash (color,hardness,soil/rock type,grain size,etc.)
4.Date Well(s)Completed:8-1-23 Well ID#D W 1-24 5 ft. 1 o rt
pRedish brown sandy clay
5a.Well Location: is ft. 35 ft' Dark grey ash
Duke Energy 35 ft• 36 ft- Native
Facility/Owner Name Facility ID#(if applicable) ft. ft e"y ;+4'E`1 if . q
8320 NC 150, Sherrills Ford, 28673 ft. ft. r� L L.%
Physical Address,City,and Zip
ft. ft. AUG 3 2023
Catawba 21.REMARKS '
Infr..fiicttCr'1 ?rot:.57. ;i' Ur':
County Parcel Identification No.(PIN) Q fv 11OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' 1
(if well field,one lat/long is sufficient) 22.Certificatio • •
35.61599 N 80.97861 W '�`%�
6.Is(are)the well(s)rjPermanent or ( iTemporary S' nature 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: DYes or EiNo with 1SA NCAC 02C.0100 or ISA 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: 36 (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:
10.Static water level below top of casing: 15.4 (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: 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:
(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 tie county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016