GW1--05669_Well Construction - GW1_20230831

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,
I
Nicholas Moreno ,14:WATER ZONES ' ,_
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4209-A ft fa
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.
Company Name 16INNER: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 we
3.Well Use(check well use): ft. ft in.
Water Supply Well: FROMCSTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public 27 ft. 47 ft. 4 In. .20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DIResidential Water Supply(single) ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring °Recovery ft. ft.
Injection Well: ft. f4 1 1
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable) - u
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test riStormwater Drainage o ft• 47 ft• aasand : Trernmie
Experimental Technology jr1 Subsidence Control ft. ft. j
Geothermal(Closed Loop) EDTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiUrock type grata size etc.)
9 it• I 5 tt. Dane grey ash
4.Date Well(s)Completed:8-17-23 Well 1D#DW2-8 5 ft' 10 ft• Radish brown sandy clay
5a.Well Location: • 'o ft. 45 ft Dark grey ash rTh
Duke Energy 45 it 47 it Native r\c L 7►1i ,,,"'^q
Facility/Owner Name Facility ID#(if applicable) ft. ft.
8320 NC 150, Sherrills Ford, 28673 ft. ft. AUG 3 1 2023
Physical Address,City,and Z 21:REMARKS; t4 into:i3Se"+;� ? .^.,. aO i ire,
Y tY. P
Catawba .: . :wI l` .._-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatio •
35.61599 N 80.97861 W
7,7a •zY
6.Is(are)the well(s)DPermanent or MI Temporary
Signature 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: JYes or EjNo with ISA NCAC 02C.0100 or 1SA 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 ifdifferent(example-3@200'and 2@l00') construction to the following: 1
10.Static water level below top of casing: 15.2 (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
i ;
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 t I 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