GW1--03679_Well Construction - GW1_20230530

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
].Well Contractor Information:
Nicholas Moreno :Ia:WATERZONEs
Well Contractor Name FROM TO DESCRIMON
4209-A ft. ft.
ft. it.
NC Well Contractor Certification Number :15:OUTER`CASING'for'multi-c5sed wells"OR LMR if:a livable
Keller Industrial Inc FROM To I DIAMETER THICKNESS MATERIAL
ft. ft. fn.
Company Name
16.INNER CASING:ORTUBING'eotheerrialcldsed-lod'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 6 ft. 6 In. Sch 40 Pvc
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
'17.-SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 6 fL 36 ft. 6 In. 20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) g. ft.
Industrial/Commercial IOResidential Water Supply(shared)
15.GROUT
1ni ation FROM -TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Welli ft: ft.
Monitoring ElRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salini Barrier FROMND/GRAVEL.PACK MATERIAL
le _ L E`...D
tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E?StorrnwaterDrainage D ft. 36 ft. to sand Tremmie
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer P 20.DRILLING LOG'aui` additiontitsheets'if necessa
Geothermal(Heating/Cooling Return) rtOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVrock type in size,eta
ID ft. 5 it- Tan Clay
4.Date Well(s)Completed:4-26-23 Well ID#DW-3 5 ft. 15 ft. sandy Clay
5a.Well Location: ,s ft. 35 ft. Ash _
Duke Energy 8etews Creek 35 tr. 36 fa Sand
Facility/Owner Name Facility ID#(if applicable)
ft. ft. MAY Z02,
3191 Pine Hall Road,Walnut Cove, NC 27052 ft. ft.
Physical Address,City,and Zip it. it.
Stokes 21.REMARKS.
County Parccl Idcntification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certificatio
36.28549 N 80.07856 W
6.Is(are)the well(s)OPermanent or MTemporary Signature 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: 0Yes or E)No with ISA NCAC 02C.0100 or ISA 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 wider#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Ceothermal 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: 36 (ft) 246. For All Wells: Subinit this fbim within 30 days of completion of well
For multiple wells list all depths if eli erent(example-3 200'and 1@100) construction to the following:
10.Static water level below to of casing:30.4
P 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: 12 (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:
(Le.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&Infection 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