GW1--05648_Well Construction - GW1_20230831

1 Pr'int Form- -
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
J.Well Contractor Information: I •
li
Nicholas Moreno ;'14.WATER ZONES". • -r, ;
Well Contractor Name FROM TO DESCRIPTION
ft ft 1 '
4209-A •
ft 1
NC Well Contractor Certification Number '15.OUTER CASING(for multi-cased wells)OR LINER(if ap"livable) '
Keller Industrial FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
• 16.INNER CASING OR TUBING(geothermal closed-loop) '"
2.Well Construction Permit#: •FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft 28 ft. 4 in' Sch 40 vvc
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Mtmicipal/Public 28 ft. 48 ft 4 in. zo Sch 40 Pvc •
Geothermal(Heating/Cooling Supply) (°Residential Water Supply(single) ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared)
'— '1&
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring °Recovery ft. ft.
Injection Well:
ft. ft. 1 i 1
Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(If applicalie),.
Aquifer Storage and Recovery °Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwaterDrainage 0 ft 48 ft- /A Send Treraware
Experimental Technology E3Subsidence Control ft. ft
Geothermal(Closed Loop) °Tracer 120.DRILLING LOG:(attoch additional sheets if necessary) - ,
FROM TO I DESCRIPTION(color,hardness,soil/rock(Heating/Cooling Return) Other(explain under#21 Remarks)
soil/rock type,grain size,etc.)
q (t- y (t. Dark grey ash
4.Date Well(s)Completed:7-24-23 Well)D#DWI-15 5 ft t0 ft Redish brown sandy clay
5a.Well Location: ,o ft. 45 ft Dark grey ash
Duke Energy 45 ft- 48 ft. Ranee
Facility/Owner Name Facility ID#(if applicable) ft. ft. F.:''�"".'t_,'-# !rv,r"'
�'
8320 NC 150, Sherrills Ford, 28673 ft ft t "`1"' • t )
Physical Address,t try,and zip ft, I (t. I H U li 3 1 2023
Catawba 2L REI►rARxs
imrs a r = era c„z,}r3 Uri
County Parcel Identification No.(PIN) DV,/(S`T,-LV
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatio •
35.61599 N 80.97861 W
6.Is(are)the well(s)rjPermanent or I Temporary Signature of Certified Well Contractor Date
i
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: jYes or E)No with 15A 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.
dulled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 48 (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: 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
11.Borehole diameter: 8 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Rota above,also submit one copy of this!form within 30 days of completion of well
Rotary
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: I 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit I 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