GW1--03672_Well Construction - GW1_20230530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Nicholas Moreno 1,44.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft
4209-A I
ft. fL
NC Well Contractor Certification Number A5.:OUTER CASING for'multi-cased wells OR LINER if a"licable
Keller Industrial Inc FROM To DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name i s
16.INNER CASING OR TUBING` eothermal-closed-lod --
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 31 ft. 2 In. Sch 40 Pvc
3.Well Use(check well use): ft. R• in.
17.SCREEN
Water Supply Well: =
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ~
Agricultural DMunicipal/Public 31 ft 41 ft. 2 in. 20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) ®IResidential Water Supply(single) ft• ft.
Industrial/Commercial (Residential Water Supply(shared) 18.GROUT
1hrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. 29 ft. Bentonite Pellets Tremmle
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge IDGroundwater Remediation
A uifer Storage and Recovery Salinity Barrier ;.19:SAND/GRAVEL PACK ifa-•Bcable
q g ry ty FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage 49 it. 41 ft- 1A Sand Tremmle
Experimental Technology ®I Subsidence Control it. It.
Geothermal(Closed Loop) Tracer 20.'DRILLING LOG,attach additional sheets if necessa
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness solUmck type rain size,eta
p (L g tt- Tan Clay
4.Date Wells Completed:4-24-23 Well EM OW-5 6 ft. 29 ft. Sand Clay
5a.Well Location: zs ft. 36 ft. Ash
Duke Energy Befews Creek 36 ft. 40 ft- Sandy Ash 3---
Facility/Owner Name Facility ID#(ifapplicable) 40 ft. 41 ft. Native Ground MAY J ,Q
3191 Pine Hall Road,Walnut Cove, NC 27052 ft, ft.
Physical Address,City,and Zip ft it
Stokes "21 REMARKS.;?
County Parccl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/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 X Temporary Signature ofCertified 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 [@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 retard has been provided to the well owner.
repair miler#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: 41 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@100) construction to the following:
10.Static water level below to casin •29•0
P of g• (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 276994636
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 lone 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