GW1--03669_Well Construction - GW1_20230530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
1.Well Contractor Information:
i
Nicholas Moreno 44.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4209-A
ft. tt.
NC Well Contractor Certification Number .15.OUTER CASING for multi " it a'
-cased wells OR LINER livable
Keller Industrial Inc FROM To DIAMETER TBICKNESS MATERIAL.
ft. ft,
Company Name
„16.INNER CASING OR TUBING.'eothermal closed-leo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 It- 33 IL 2 In. Sch 40 avc
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN,. .4'_ :... ,._.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public 33 ft 43 ft. 2 1°' 20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) [3Residential Water Supply(single) fL ft.
Industrial/Commercial Residential Water Supply(shared) IS:GROUT 5 -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 31 ft Bentonite Pellets Tremmie
Monitoring Recovery ft ft.
Injection Well:
ft.
Aquifer Recharge Groundwater Remediation D/
>'19:SAND/GRAVEti',PACK if a"'licalile '
Aquifer Storage and Recovery [I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD,
Aquifer Test f)Stormwater Drainage 31 ft• 43 It. 1A Sand Trenum
Experimental Technology Subsidence Control It. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additi6datsheets if necessa
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sell/rock type,grain size,etc.
t) R• b (L Tan Clay
4.Date Well(s)Completed:4-20-23 Well ID#OW-2 6 ft. 20 ft. Sand Clay
5a.Well Location: 20 ft. 39 ft. Ash
Duke Energy Befews Creek 39 ft, 43 ft, Sandy Ash
Facility/Owner Name Facility ID#(if applicable) 43 ft. 43 ft. Rock MAY
3191 Pine Hall Road, Walnut Cove, NC 27052 ft. ft.
Physical Address,City,and Zip 4t ft. In+vf°V` 'f:~J p' ' i<a
of
Stokes
21.'REMARKSh;`' v;a
County Parcel Identification No.(PN
5b.Latitude and longitude in degrees/minutes/seconds or decfmaf degrees:
(if well field,one fat/long is sufficient) 22.Certification•
36.28549 N 80.07856 W
6.Is(are)the well(s)OPermanent or OTemporary rgnature 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 X)No with ISA 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:
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: 43 (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:22.8 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Infection 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 Resources Revised 2-22-2016