GW1--05650_Well Construction - GW1_20230831

�Prirtf Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Nicholas Moreno .14.WATER'ZONES a ' A. r" "
Well Contractor Name FROM TO DESCRIPTION
ft. ft. I I
4209-A
ft. ft. 1 1
NC Well Contractor Certification Number 15.OUTER CASING(for multl-cased wells)OR LINER(if ap licable) •
Keller Industrial FROM TO DIAMETER f THICKNESS g MATERIAL
ft. ft. i, in. •
CompanyName -16.'INNER CASINGORTUBING' geothe mal'closed-loop)' a: c' - -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft• 25 ft. 4 in. Sch 40 Pvc
3.Well Use(check well use): ft. ft in.
Water.Supply Well:
FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
Agricultural. QMunicipal/Public 25 ft• 45 ft• 4 ill .20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery ft. ft. '
Injection Well:
Aquifer Recharge Groundwater Remediation ft. 1
-'19.SAND/GRAVEL PACK(if applicable)''' ` , , ow
Aquifer Storage and Recovery ®I Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwaterDrainage 0 ft- 45 ft- I Trerople
Experimental Technology IDSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer "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) q ft- 5 ft• 'Dark grey asn
4.Date Well(s)Completed:7-28-23 Well ID#DWI-17 5 ft. 10 ft. Redish brown sandy clay
Sa.Well Location: ,a ft. 44 ft. Dark grey ash
Duke Energy44 ft, 45 ft- Native F! T., -
C�*#i`$\/ -'.0
Facility/Owner Name Facility ID#(if applicable) ft. ft.
8320 NC 150, Sherrills Ford, 28673 ft. ft. AU U 3 i 2023
Physical Address,City,and Zip tt. tt. i In rr?S;%m Pr"-C*4.14:1W Urt$
Catawba 21.REMARKS; .. . . ., .'.. . ENkps`n#:1iT4
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certificati
35.61599 N 80.97861 Rr .�'�
7,ZG -Z?
6.Is(are)the well(s)rJPermanent or EllTemporary 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 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: - -- - SUBMITTAL INSTRUCTIONS i
9.Total well depth below land surface: 45 (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 1@I00) construction to the following:
14.9 j
10.Static water level below top of casing: (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 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:
(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&Injection 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