GW1--05643_Well Construction - GW1_20230831

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i ,
Nicholas Moreno 14.WATERZONES' •a
FROM TO DESCRIPTION
Well Contractor Name f '
ft. ft.
4209-A fr. ft
NC Well Contractor Certification Number 15.OUTER?CASING(for multi-cased wells)OR LINER(ifap licable)
Keller Industrial FROM TO DIAMETER THICKNESS MATERIAL
It. ft. in.
Company Name
_ 16.INNER CASING OR TUBING(geothermal closed-loop) i
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 27 ft. 4 in. Sch 40 we
3.Well Use(check well use): ft. ft. is
17.SCREEN,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 27 ft. 47 ft. 4 in. ' .20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) ( Residential Water Supply(single) ft. ft. in.
Industrial/Commercial 0 Residential Water Supply(shared) IS."GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Injection
Recovery ft. ft.
njection Well: ft. I ft.
Aquifer Recharge IQGroundwater Remediation
19.SAND/GRAVEL PACK(If applicable)'` - '- - " -°" n.
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °StormonterDrainage 0 ft. 47 ft. IA Sand ' Treamtie
Experimental Technology 0 Subsidence Control ft. ft. J
Geothermal(Closed Loop) E3Tracer --20.DRILLING LOG(attach additional sheets if necessary)'.,.. ,
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ti tt. 5 tt» Dark grey aslr
7-21-23 DW1-10 5 ft. to ft
4.Date Well(s)Completed: Well ID# Redish brown sandy clay
5a.Well Location: ,e ft. 45 ft. Dark grey ash
Duke Energy 45 fL 4r ft: Native .
Facility/Owner Name Facility IDit(if applicable) ftr
8320 NC 150, Sherrills Ford,28673 ft. ft. dr • ��-+^L1
Physical Address,City,and Zip ft• I to I A V 6 3 1 2023
Catawba `21.REMARKS,-,..__ .,-. : _ ,,:a :T .y.
IfhciriY3Jlr41 .1afs2l tl
County Parcel Identification No.(PIN) QV.C.,'nocY
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatio .
35.61599 N 80.97861 R
P,7U- z3
6.Is(are)the well(s)ljPermanent or Temporary 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: DYes or EgNo with 15A NCAC 02C.0100 or 1SA 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:
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-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: 47- (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following: i , -
i
10.Static water level below top of casing: 15.3 (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: 8 (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:
(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&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources • Revised 2-22-2016