GW1--03675_Well Construction - GW1_20230530

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Nicholas Moreno I"14:,WATERZONES -
Well Contractor Name FROM TO DESCRIPTION
ft. fL I i
42-09-A
ft. tL
NC Well Contractor Certification Number 15..OUTER CASING forTfilti-cased:wells OR-.LINER=if a' licable
Keller Industrial Inc FROM To DIAMETER THIctavEss MATERIALI
ft, ft. in.
Company Name
16.INNER CASING OR TUBING eother al closed-lao"
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 fL 34 fL 2 In. Sch 40 PVC
3.Well Use(check well use): ft.. ft. in.
17.SCREEN. .,.,,,,_
Water Supply Well: FROM TO DIAMETER SLAT SIZE TIUCKNESS MATERIAL
Agricultural E)Municipal/Public 34 It. 44 ft. 2 in. 20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) ®IResidential Water Supply(single) ft. ft.
Industrial/Commercial [Residential Water Supply(shared) IS:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 32 fL Bentonite Pellets Tremmle
Monitoring 1311ecovery fL ft
Injection Well:
ft. fL
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL".PACK if a lcable
Aquifer Storage and Recovery Salinity Barrier FROM To I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage 32 ft. 44 ft. pA sand Tremmle
Experimental Technology E3Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if nectissa
Geothermal(Heating/Cooling Return) n0flier(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soulrock type rain size,etc
D ft. b It- 'Tan Clay
4.Date Well(s)Completed:4-20-23 Well ID#OW-7 6 ft. 20 fL Sand Clay
5a.Well Location: 20 ft. 39 fL Ash
Duke Energy Befews Creek 39 ft 43 fL Sandy Ash
Facility/Owner Name Facility ID#(if applicable) 43 ft. 43 ft. Native Ground
3191 Pine Hall Road,Walnut Cove, NC 27052 ff. ft.
Physical Address,City,and Zip ft. ft lily 7r'}jC l l C^C;A?'l�Yr i
Stokes 21.REMARKS" ""
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Certificati
36.28549 N 80.07856 W
6.Is(are)the well(s)OPermanent or MTemporary '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: ®Yes or E)No with 1 SA 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 erplain 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:
S.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: 44 (fL) 24a. For All Wells: Submit this fora within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100) construction to the following:
10.Static water level below to 15.0
p of casing: (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 276994636
13a.Yield(gpm) Method of test: 24c.For Water Supply&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