GW1--03671_Well Construction - GW1_20230530

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
Nicholas Moreno ;'14.WATER ZONES i`
Well Contractor Name FROM TO DESCRIPTION
It.
ft
4209-A
It. ft.
NC Well Contractor Certification Number 15._OUTER'.CASING.far'multi cas`ed'ivells.ORLIlVER`if a`"licable
Keller Industrial Inc FROM To DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TIJBING'(eothermaldosed-loo'
2.Well Construction Permit#: FROM I To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits C.e.UIC,County,State,Variance,etc.) 0 ft. 30 ft. 2 In. Sch 40 -c
3.Well Use(check well use): ft. % in.
Water Supply Well:
17.SCREEN,, ..1—
FROM TO DIAMETER � SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public 30 IL 40 ft. 2 in. 20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) fL ft. in,
Industrial/Commercial Residential Water Supply(shared)
IS:GROUT-
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 30 ft. Bentonite Pellets Tremmle
:)monitoring 1311ecovery ft. IL
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
219..SAND/GRAVEL PACK d a"'livable "
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage 30 f- 40 ft, 1A Sand Tremmie
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 30.DRILLING LOG'attach additional sheets if necessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,saillroek type rain s' etc
9 ft. b tt. Tan Clay
4.Date Well(s)Completed:5-2-23 Well ID#OW-4 6 ft. 15 ft. sand Ah
5a.Well Location: 15 ft. 39 ft. Ash ^c a 'Y 31 z i:"n
Duke Energy Belews Creek 39 ft. 40 ft- Native Ground
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAY
3191 Pine Hall Road,Walnut Cove, NC 27052 ft. ft. , as :_ UWA
Physical Address,City,and Zip ft. tt
y ty, p
Stokes 21.REMARKS 0,'
County Parcel identification No.(PIN)
5b.Latitude and longitude in degreestminutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.28549 N 80.07856 W
6.Is(are)the well(s)oPermanent or XOTemporary 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 E)No with 15A 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: 40 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3@200'and 2@100) construction to the following:
10.Static water level below to of 28.3
p casing: (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 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: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: 24c.For Water SunDly&Inlection 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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