GW1--05685_Well Construction - GW1_20230831

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Nicholas Moreno '1,V WATER ZONES ,. z . ,Al. ,4' ; ,
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4209-A .
ft. ft.
NC Well Contractor Certification Number ,:15.OUTER;CASING(for"itiultiecased wells)OR'LINER`(if a1 licable) ,,
Keller Industrial FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name •
6 16;INNER.C;4 SING OR TUBING`(geothermal closed.loop); ' %6. ;?-
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft• 28 ft• 4 ! in' Sch 40 PVC
3.Well Use(check well use): ft. ft. ; in.
Water Supply Well: -;17.`SCREEN ,, =-a= " A": ::
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 28 ft 48 ft. 4 in: .20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft in;
Industrial/Conunercial i*'Residential Water Supply(shared) 218.GROUT ,,tl- f:= f."':-:
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring EDRecovery ft. ft. '
Injection Well: '
Aquifer Recharge DGroundwater Remediation f
19:'SAND/GRAVEL.PACK(If applicable) ,.`. ":-
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD .p
Aquifer Test OStotmwater Drainage 0 ft• as ft. 1A Send! Treratei4
Experimental Technology 0 Subsidence Control ft ft.
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Geothermal(Closed Loop) °Tracer '20:DRILLING LOG(attach additloual'"sheets if necessary). , ,`...,..F;t:.., ,
FROM tt• TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
Is Daf c grey ash
4.Date Well(s)Completed:7-20-23 Well ID#DWI-7 5 ft• 10 ft Redish brown sandy clay
5a.Well Location: 10 ft. 45 ft Dark grey ash
Duke Energy 45 f 46 ft- Native i
Facility/Owner Name Facility ID#(if applicable) ft. ft '• ^^�
8320 NC 150, Sherrills Ford, 28673 ft. ftR �° ' �-y
Physical Address,City,and Zip St. i• AUG 2023
Catawba v=21;REMARKS, .,. :: -- e :...F Z_. .,>r x '.
I lnt'irfrlr'iiwl f rc-C•= 4:el tjtn
County Parcel Identification No.(PIN) n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.61599 N 80.97861 R, '
PrZO -Z Z
6.Is(are)the well(s)DIPermanent or 1 Temporary S tore of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EINo 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 I
9.Total well depth below land surface: 48 (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 2Q100) construction to the following: '
i
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,4 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.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C,nter,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 the county health department of the county
where constructed. 1
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016