GW1--03676_Well Construction - GW1_20230530

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Nicholas Moreno 114:WATERtZONEs-,. '•. s
Well Contractor Name FROM ft. TO ft �DESCRIPTION
4209-A
R. ft
NC Well Contractor Certification Number 155OUTER CASING fo"rmdlticased'wells OR LINER' u"``licatile
Keller Industrial Inc FROM TO DIAMETBR THICKNESS MATERIAL.
ft fti I i I--L
in.
Company Name
16.INNER CASING OR TUBING ebth6rmal closed-loo
2.Well Construction Permit#: FROM I TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft- 60 ft- 2 In. Sch 40 we
3.Well Use(check well use): ft. ft in.
Water Supply Well:
17..SCREEN�,- ,.-
FROM TO DIAMETER SLOT SIZE THICKNESS - MATERIAL.
Agricultural []Municipal/Public 80 ft 70 ft 2 in. 20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
X Industrial/Conunercial Residential Water Supply(shared) 18:GROUT
-
1ni tion PROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 58 ft. Bentonite pellets Tremmle
Monitoring Recovery ft ft
Injection Well:
ft. ft
Aquifer Recharge []Groundwater Remediation
-19.SAND/GRAVEL PACK if a• •licable
Aquifer Storage and Recovery ©ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E2Stormwater Drainage 58 ft, 70 ft. 1A Sand Trenrmie
Experimental Technology Subsidence Control ft. ft,
Geothermal(Closed Loop) OTracer 20.DRILLING'LOG:attach addiHdnatsheets if necessary),
-
FROM TO DESCRIPTION color,hardness,soiltrock' e, rain size,etc.
RGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
ll it. 5 ft• Tan Clay
4.Date Well(s)Completed:4-21-23 Well ID#OW-9 5 ft. 65 ft. Sand Clay
5a.Well Location: ss ft. 68 It. Ash r,
ft 70 ft Sandy Ash S v�..\..�JL—ii r' 4-.,
Duke Energy Befews Creek ,�,)�
Facility/Owner Name Facility ID#(if applicable) 70 ft. ro ft. Native Ground MAY J
3191 Pine Hall Road,Walnut Cove, NC 27052 ft. ft.
Physical Address,City,and Zip It. ft. f1S`v;i,
Stokes 21.RENIARK.S�:;:
County Parcel 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)C3Permanent or OTemporary ignature ofCertified Well Contractor Date
By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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 tivell owner.
repair under 921 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 ifdifferent(example-3@200'and 2@100) construction to the following:
2
10.Static water level below top of casing:23. (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Inlection 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&Inlection Wells: In addition to sending the form to
the address(es) above, also submitl one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to ithe county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016