GW1--03667_Well Construction - GW1_20230530

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,
Nicholas Moreno 44:WATER ZONES .
Well Contractor Name FROM TO DESCRIPTION
4209-A
ft. fL
NC Well Contractor Certification Number OUTER CASING for"multi cased wells'.ORLINER ifa leable'
Keller Industrial Inc FROM TO DIAMETER THICIQVESS MATERIAL
ft ft 1 in.
Company Name
-16:.INNER CASING OR TUBING`(eothermal closed-loo .,.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 10 ft 6 tn' Sch 40 rvc
3.Well Use(check well use): ft. & in.
Water Supply Well: 17.SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IOMtmicipal/Public 10 ft 40 ft 6 in- 20 Srh40 PVC
Geothermal(Heating/Cooling Supply) ®IResidential Water Supply(single) ft ft. in.
Industrial/Commercial []Residential Water Supply(shared)
GROUT :=;' ._.:�. .,,
Irrigation FROM TO I MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring DRecovery ft ft
Injection Well: fL it
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if`a livable
Aquifer Storage and Recovery ®ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStornlwater Drainage 0 ft. 40 ft 1A Sand Tremmie
Experimental Technology []Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 1-20.DRILLING LOG attach additional sheets if neeessa
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soRtrock type,grain size,etc
D ft- 9 tt• Tanaay
4.Date Well(s)Completed:5-1-23 Well lD#DW-1 O g ft. 20 ft Sandy Clay with light signs of ash
5a.Well Location: 20 ft. 37 ft' sand with signs of ash
Duke Energy 8etews Creek 37 ft 40 ft Sand f ;,
Facility/Owner Name Facility ID#(if applicable) ft. ft. -
3191 Pine Hall Road,Walnut Cove, NC 27052 ft ft MAY 3 0 Z9Z3
Physical Address,City,and Zip ft• f1L a R l hR
Stokes z1:-REMARKS'''.. "�". ... . •. :,,: ..
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.Certit'icatio
36.28549 N 80.07856 W
s-if-z9P
6.Is(are)the well(S)IOPermanent or OTemporary 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: [3Yes or XINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell 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 thisform.
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-i 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 (fW 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 to of easing:27.7
P g: t.
Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+'• 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 12 (in.) 24b.For Iniection 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 276994636
13s.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
131b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016