GW1--03670_Well Construction - GW1_20230530

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Nicholas Moreno ,14:wATERZONEs
FROM TO DESCRIPTION
Well Connector Name I ;
ft, ft.4209-A
ft. ft. '
NC Well Contractor Certification Number 35.OUTER CASING for'multi�ased wells ORLINER-(If a licable
Keller Industrial Inc FROM TO DIAMETER THIC"WSS nIATERIA
ft. ft. in.
Company Name
"16.INNER.CASING OR TUBING( eothermal closed-loo
2.Well Construction Permit#: FROM I TO I DIAMETER THICKNESS t17ATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) 0 ft- 27 ft. 2 In. Sch 40 rvc
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: 47.SCREEN .:.r;.
FROM TO DIAMETER SLOT SIZE THICKNESS ' MATERIAI,
Agricultural E3Municipal/Public 27 ft, 37 ft. in. 20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft. ft. in,
X Industrial/Commercial [JResidential Water Supply(shared)
18.GROUT-
lIrrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 27 ft. Bentonite Pellets Tremmle
Monitoring Recovery ft. ft.
Injection Well: ft ft.
Aquifer Recharg E3Groundwater Remediation
19.SAND/GRAVEE PACK if a `lieable "
Aquifer Storage and Recovery DSalinity Barrier FROAI TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E2Stormwater Drainage 025 if• 37 ft. OA Sand Tremmie
Experimental Technology Subsidence Control ft. %
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnes soil/rock type mins etc.
0 it- g ft. TanCtay
4.Date Well(s)Completed:4-19-23 Well ID#OW-3 6 ft. 37 ft. Sand Clay
5a.Well Location: ft. ft.
Duke Energy Betews Creek
Facility/Owner Name Facility ID#(if applicable) ft. ft
3191 Pine Hall Road,Walnut Cove, NC 27052 ft. fL MAY 3 0 Z023
Physical Address,City,and Zip UL ft din [O� u w}T�Rif?:i
REMARKS
Stokes zL ,A.
County Parcel Identification No.(PIN)
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification
36.28549 N 80.07856 W
6.Is(are)the well(s)OPermanent or OTemporary gnature of Certified Well Contractor Date
By signing this form,I hereby certfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fdl 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: 37 00 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 2Qa 100) construction to the following:
10.Static water level below top of casing:21.7 (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: 6 (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:
(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 Suauly&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 Revised 2-22-2016
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