GW1--05645_Well Construction - GW1_20230831

TPrint Form-
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I , .
Nicholas Moreno
We1lConhactorName FROM TO DESCRIPTION
ft. fL
4209-A ft. I rL I 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased;Neils)OR LINER(if ap licable)-
Keller Industrial FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft. in.
Company Name .-16:INNER CASING,OR'TUBING( eothei-mal"closed-loop)' - ` r"'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i,e.UIC,County,Stale,Variance,etc.) 0 ft- 27 ft• 4 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 27 ft". 47 fL 4 in', .20 Sch 40 PVC
0 Geothermal(Heating/Cooling Supply) jResidential Water Supply(single) ft ft. in.
Industrial/CommercialResidential Water Supply(shared) ` ' ` '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Non-Water ft.Monitoring Recovery ft. ft.
Injection Well: .
Aquifer RechargeDGroundwater Remediation ft. I ft.19.SAND/GRAVEL PACK(if applicable) ....--
AquiferStorageandRecovery I�SalinityBarrier FROM TO MATERIAL METHOD
Aquifer Test StarnreveterDraintzge la ft• 47 ft I IASend Tramrme
Experimental Technology Subsidence Control ft. ft.Geothermal(Closed Loop) Tracer -.,20.DRILLING LOG:(attach additional'sheets ifnecesiary)A -- :w- �= ,,
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO " I DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
9 It. 5 It. Dant grey ala
4.Date Well(s)Completed:8-2-23 Well ID#DWI-12 5 ft• 10 ft* Redish brown sandy day_
5a.Well Location: i0 ft' 45 ft' Dark grey ash
Duke Energy 45 ft. 47 ft- Native
Facility/Owner Name Facility ID#(if applicable) ft. ft.
8320 NC 150, Sherrills Ford, 28673 ft. ft. p s'— •r,
Physical Address,City,and Zip 1 ft• ft. 1
Il^'Y l..i
Catawba '21:REMARxs: -- f rAUf 3i1 a'':"201 •,,hr_ -�.
J �J
County Parcel Identification No.(PIN)
{ IfhT.:: £fl arrCor 2 UIly
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ' [)'v 1a'3' r
(if well field,one 1at/long is sufficient) 22.Certitleati
35.61599 N 80.97861 w
2P,ZU'z3
6.Is(are)the well(s)iPermanent or Temporary Signature of Certified Well Contractor I Date
I
By signing this form,I hereby cent/that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or jNo 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 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 attach additional pages if necessary.
drilled: I
SUBMITTAL INSTRUCTIONS i
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 ifd�erent(example-3(200'and 2Q100') construction to the following: 1:
10.Static water level below top of casing: 15.1 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
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 i enter,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-I North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016