GW1--05670_Well Construction - GW1_20230831

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor 7nformatiwi:
'
Nicholas Moreno 14.WATER ZONES-
FROM TO DESCRIPTION
Well Contractor Name
ft ft
4209-A ft. ft.
1
NC Well Contractor Certification Number 15.OUTER CASING(forMulti-cased wells)OR LINER(If ap Beagle)- r.
,
Keller Industrial FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name ,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. 20 ft 4 1°• Sch 40 we
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:.SCREEN "
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural I3Municipal/Public 20 ft 40 ft. 4 in. .20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) '
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery ft. ft.
Injection Well: ft I ft.
Aquifer Recharge ID. Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage 0 ft. 40 ft. t,ASend Treanme
Experimental Technology DSubsidence Control ft ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary),_ ' ' ' - "=
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
_ Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
9 ft• 5 St• Dafu grey ash _
4.Date Well(s)Completed:8-17-23 Well ID#DW2-9 5 R• 10 ft a�Redish brown son
5a.Well Location: ,° ft 38 ft Dark grey ash u
Duke Energy 36 ft. 40 ft Native ' AUG 3 1 202J
Facility/Owner Name Facility ID#(if applicable) ft. ft ar w1 fC r,- l tr_;(
8320 NC 150, Sherrills Ford, 28673 ft ft lal f p+OOOCs
Physical Address,City,and Zip U. U. '
Catawba 21.REMARKS.:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreesfrninutesfseconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.61599 N 80.97861 W
7zo.- zr
6.Is(are)the well(s)DPermanent or Temporary ,gnature of edified 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 23No with 15A NCAC 02C.0100 or 15A 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:
S.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 if different(example-3@200'and 2@100') construction to the following: ,
10.Static water level below top of casing: 14.3 (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 Ipjection 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.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: J 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 to the county health department of the county
where constructed. I '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource! Revised 2-22-2016