GW1--03678_Well Construction - GW1_20230530

Print Form.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Nicholas Moreno WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
4209-A ft.
NC Well Contractor Certification Number rt. fL
15.'OUTER CASING(for' ultimcased Wells)0 able)T_�=apqliL
Keller Industrial Inc FROM TO DIAMETER MATERIAL
Company Name m I ft. I I.. I I I
1,16.INNER CASING OR TUBING(geotluifmal closedim-ldoo)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 It- 50 ft 2 in. S ch 40 Pvc
3.Well Use(check well use): ft ft. in.
FWater Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IDMunicipal/Public *5" fL 60 fL 2 in. 20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) [21tesidential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared)
Ig.GROUT-
I FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 48 ft- Bentonite Pellets Tremmle
:lMonitoring DRecovery ft. ft.
Injection Well: ft. ft.
3Aquifer Recharge DGroundwater Rernediation
19.SAND/GRAVEL PACKif applicable)
3Aquifer Storage and Recovery Salinity Barrier TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStofrnwater Drainage 48 ft. 60 ft- 1A SwO Tremmie
Experimental Technology Subsidence Control ft. ft.
P fit
Geothermal(Closed Loop) OTracer 10.DRILLING LOG attach additional sheets lfnecessa
Geothermal(Heating/Cooling Return) Mother(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rack type�grain size,etc.)
D ft. b it- -Tan Day
4.Date Well(s)Completed:4-21-23 - Well ID#OW-10 6 ft. 49 fL Sand Clay
5a.Well Location: 49 ft. 56 ft. Ash
Duke Energy Befews Creek 56 ft. 0 ft- Sandy Asti RZ 7C_C_'U keylt L
Facility/Owner Name Facility ID#(if applicable) 59 ft. figfL Native Ground MAY 3 0 2023
3191 Pine Hall Road,Walnut Cove, NC 27052 ft. ft.
Physical Address,City,and Tip ft. (t. 1,1h,
Stokes '21.RENLIUM i_;V,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifivell field,one lattlong is sufficient) 22.Certification:
36.28549 N 80.07856 W
6.Is(are)the well(s)oPermanent or OTemporary 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 EJNo with 15A NCAC 02C.0100 or 15A NCIC 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:
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 I 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: 60 (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:
10.Static water level below top of casing:20.0 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater 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 27699-1636
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;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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016