GW1--03680_Well Construction - GW1_20230530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print F6rrn='--
1.Well ContractorInformation:
Nicholas Moreno .,f4 WATER ZONES'!�_":-�;�,','��__'
Well Contractor Name FROM TO DESCRIPTION
4209-A .t ft.
ft. ft.
NC Well Contractor Certification Number f
Keller Industrial Inc 15.'OUTER CFROM ASING for multi--ells,IAMETER OR LINER
a119&i
ft. in.
Company Name I
,16.INNER CASING OR TUBING(ge6th6rmal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.) 0 It. 10 ft. 6 in. Sch 40 rvc
3.Well Use(check well use): ft. ft. in.
17.-SCREEK-­&-,� n_' � ­. ,L.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
—)Agricultural OMunicipal/Public 10 ft- 40 ft. 6 in. 20 Sch 40 PVC
DGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) f, ft. In.
XI)Industrial/Commercial 13Residential Water Supply(shared) I&GROUT,
IhTigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
)Monitoring EiRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge E3Groundwater Rernediation
19:SAND/GRAVEL PAC
3Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACFATENT METHOD
:)Aquifer Test DStormwater Drainage 0 ft- 40 ft- 1A sand Treirrarie
:)Experimental Technology OSubsidence Control ft. ft.
RGeothermal(Closed Loop) []Tracer 20.DRILLING LOG attnch additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM I TO — DESCRIPTION(color,hardaes soil/rack type, rains etc.)
D CIL b it. 'Tan 0ay
4.Date Well(s)Completed:5-3-23 Well ID#DW-4 6 14 It. Sandy Clay
5a.Well.Location: 14 ft. 39 ft. Ash V tz—
Duke Energy Belews Creek 39 ft, 40 & Sand Mff 3 0 Z0213
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3191 Pine Hall Road,Walnut Cove, NC 27052 ft. %
Pr: ur-i
Physical Address,City,and Tip ft. ft.
Stokes
:21:REMARKS.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreeshdnutes/seconds or decimal degrees:
(ifwcU field,one lattlong is sufficient) 22 Certification-
36.28549 N 80.07856 W -7
6.Is(are)the well(s)opermanent or OTemporary ffgaature 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: [3Yes or EJNo with 15A NCAC 02C.0100 or 15A 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:
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-I 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: 40 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifelifferemr(example-3@200'and 2@100) construction to the following:
10.Static water level below top of easing:28.32 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 12 (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