GW1--05644_Well Construction - GW1_20230831

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Weil Contractor.Infor-mation:
1 1
Nicholas Moreno ;:14.WATER.zoNES„ ,;" =r r 4 a 4
FROM TO DESCRIPTION
Well Contractor Name `
ft ft.
4209-A ft. l it. .1
NC Well Contractor Certification Number -15 OUTER'CASING'(for'inultI-eised'wells)Olt LINER(if applicable)
Keller Industrial FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
Company Name a 2
16..INNER'CASINGOR•TUBING'(geotbei'm5l ilosed loop)`; ,. ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 fL 27 ft, 4 In' Sch 40 avc
3.Well Use(check well use): ft. ft. hi.
,-17.SCREEN:::`, `.,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL 1
Agricultural OMunicipal/Public 27 ft
47 it in. ' 20 Sch4o PVC
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft in.
X Industrial/Commercial E3Residential Water Supply(shared) .;18:GROUT ,,.: .y i•;u .. .'a . .,<. .„ . =
Irrigation FROM TO ar MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring EIRecovery ft. tt.
Injection Well:
ft. I fL
Aquifer Recharge °Groundwater Remediation
,49..SAND/GRAVEL PACK(if applicable). ; . ,;,,.. ..‘. .._:
Aquifer Storage and Recovery ET Salinity Barrier FROM TO I MATERIAL 1 EMPLACEMENT METHOD
Aquifer Test rStormwaterDrainage .0 ft. 47 ft. VI Send , rrsvnrmi
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer "20.DRILLING LOG,(attneh additional sheets if necessary), .
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sae,etc.)
Geothermal(Heating/Cooling Return) InOther(explain under#21 Remarks)
p ft, g It- Dank grey ash -
4.Date Well(s)Completed:7-21-23 Well ID#DWI-11 5 ft. 10 ft' Redish brown sandy clay
5a.Well Location: 10 ft' 45 ft' Dark grey ash
Duke Energy us to 4T IL Native
Facility/Owner Name Facility ID#(if applicable) ft. ft J ` f r,7,..
8320 NC 150, Sherrills Ford, 28673 rt. It. I ‘ ..��✓�..i. fi C.-U
Physical Address,City,and Zip ft, l ft. I ll l'n'23
`21:REI4IARKS'` s
', ''
Catawba - . ., .. .
County Parcel Identification No.(PIN) int`tarcr,aaUct t rPrrsc.wrgeg l'P`k
VW Vitlgt-gii
5h.Latitude and longitude in degreesfminutes/seconds at detiatat degrees: 1
(if well field,one tat/long is sufficient) 22.Certificatio
35.61599 N 80.97861 W
6.Is(are)the well(s)DIPermanent or X�Temporary tore 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: ®Yes or ONo with 1SA 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 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also i attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS,
9.Total well depth below land surface: 47 (fL) 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: '
14.9 i
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If wafer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (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: j
(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&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 ti the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016