GW1--05680_Well Construction - GW1_20230831

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information:
Nicholas Moreno 114.WATER.ZONES i
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4209-A ft. ft.
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 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• 2 in. Sch 40 Pvc
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 20 ft• 40 ft• 2 in. .20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft. in.
Industrial/Commercial DResidential Water Supply(shared) '18.GROUT-
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery ft. ft.
Injection Well: ft. 1 ft.
Aquifer Recharge 0 Groundwater Remediation
'19.SAND/GRAVEL PACK(if applicable) -
Aquifer Storage and Recovery OSalinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test E3StrxtnwaterDrainage 0 ft. 40 ft. IASandd Traatmre
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 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)
b tt- 5 tt• Date grey ash
4.Date Well(s)Completed:8-16-23 Well ID#DOW-4 5 ft• 10 ft* Redish brown sandy day
5a.Well Location: ,o ft. 38 ft. Dark grey ash .e .7!"---t lvf i '\
Duke Energy 38 fr. 40 It• Native; RE >:z
Facility/Owner Name Facility ID#(if applicable) ft. ft. ; • D y 973
8320 NC 150, Sherrills Ford,28673 ft. ft. AUG
J r.- *-t+v.:-6 11 r.
Physical Address,City,and Zip ft.. u I inforr1 i1 t ,•t ;
Catawba 21.REMARKS G� ` j _
County Parcel Identification No.(PIN)
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaVlong is sufficient) 22.Certification
35.61599 80.97861 N �t
7•ZO -z3
6.Is(are)the well(s)rPermanent or 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: DYes or }No with ISA 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: 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(4;100') construction to the following:
10.Static water level below topof casing: 14.9
l;• (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:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I 1636 Mail Service Tenter,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 I Revised 2-22-2016