GW1--05653_Well Construction - GW1_20230831

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Nicholas Moreno •14.WATER'ZONES 'L.: v:- ,- :r-,--2, . .:- -k,a,. _.
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4209-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'wells)OR LINER(if ap licable)" ; -
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(Le.U1C,County,State,Variance,etc.) 0 ft• 17 ft• 4 In. Sch 40 we
3.Well Use(check well tise)t ft. ft in.
17.Water Supply Well: FROM SCREEN-TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public 17 ft• 37 ft• 4 in. .20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) "II 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 ORecovery ft. ft.
Injection Well:
ft. I ft.
Aquifer Recharge DGroundwater Remediation
19 SAND/GRAVEL PACK(if applicable) = _ -
Aquifer Storage and Recovery °Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test lii.StormwaterDrainage 0 ft• 32 ft PA Sand Treaanie
Experimental Technology 01Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) °' '
FROM TO DESCRIPTION(color,hardness,solltrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) rtOther(explain under#21 Remarks)
4 ft- 5 it• Date grey ash
4.Date Well(s)Completed:7-19-23 Well ID#DW 1-2 5 ft. 10 iG Redish brown sandy clay
5a.Well Location: 10 ft. 36 ft. Dark grey ash
Duke Energy 3e ft• sr ft' IVaove r 1\t C E 1, it f
Facility/Owner Name Facility ID#(if applicable) IL ft. . ' 7 y
8320 NC 150, Sherrills Ford, 28673 ft. ft. AUG 3 ± 2023
Physical Address,City,and Zip £t' I I lniirill.`i.cn?r -Cutaii g Lin
Catawba a1 RENIARKsi, , ,,.,-,5 ,-,-.,:.”:i,A: , „y- e V,1(2i8°C
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(if well field,one let/long is sufficient) 22.Certitieatio '
35.61599 N 80.97861 Rr �'`�
6.Is(are)the well(s)rjPermanent 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: f Yes or [MNo 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
9.Total well depth below land surface: 37 (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
10.Static water level below top of casing: 14.6 (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 r 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:
(ie.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: 24e.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 ti the county health department of the county
wash-acted.-acted.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016