GW1--03674_Well Construction - GW1_20230530

Point Form
WELL CONSTRUCTION RECORD(GW-1) For lntemal Use Only:
1.Well Contractor Information:
Nicholas Moreno IA:-WATER=ZONEs ..
Well Contractor Name FROM TO DESCRIPTION
4209-A ft, ft.
ft. ft.
NC Well Contractor Certification Number ISt:OUTER EASING for innit!cased wells OR LINER if a"'lieable
Keller Industrial Inc FROM TO DIAMETER THICKNESS MATERIAL
rt. ft in.
Company Name
':16:INNER CASING OR TUBING'("cothei•mal closed-loo`" '
2.Well Construction Permit#• FROM I TO DIAMETER THICKNESS hfATFRrer.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 fL 60 ft. 2 In. Sch 40 we
3.Well Use(check well use): ft. ft. in.
Water Supply Well: :I7.&GREEN:u;:__ ".__ , ,_. _.;._... .: :.. _ y,.�:,�.,.`.__. _: . ::::> • ,v;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 60 fL 70 ft. 2 in. 20 Sch40 PVC
Geothermal(Heating/Cooling Supply) ®IResidential Water Supply(single) ft. ft.
X Industrial/Commercial Residential Water Supply(shared) is GROUT
+ .
1ni tion FROM TO� MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 58 ft. Bentonite Pellets Tremmie
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a livable_ '
Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStorrnwsterDrainage 58 ft- 70 ft. to Sand Tremmie
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG.attach additional sheets if necessary):
RGeothermal(Heating/Cooling Return)
TO DESCRIPTION(color.hardnes soillmek e,grain s etc.) Other(explain under#21 Remarks) o ft. 5 ft. Tan aay
4.Date Well(s)Completed:4-21-23 Well ID#OW-8 5 ft. 70 ft• Sand Gay
5a.Well Location: fL fL No Ash
Duke Energy Betews Creek
s
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3191 Pine Hall Road,Walnut Cove, NC 27052 ft. ft MAY
Physical Address,City,and Zip ft, ft. �.
Stokes
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/mfnutes/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 inure 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: []Yes or EJNo with 15.4 NCAC 02C.0100 or 15.4 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: 70 (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 1 construction to the following:
10.Static water level below to casin •22.4
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 (jn.) 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 SuDDIv&Iniection 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. I I '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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