GW1--05655_Well Construction - GW1_20230831

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r Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: +
Nicholas Moreno 14.WATER ZONES " ' ' :" ..
Well Contractor Name FROM TO DESCRIPTION
4209-A rt. ft
ft ft. l I
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(i.e.UIC,County,State,Variance,etc.) 0 ft 24 ft 4 in. Sch 40 avc
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
;17.SCREEN .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural I°Municipal/Public 24 ft 44 ft 4 in. 20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in..
Industrial/Commercial OResidential Water Supply(shared) r
18.Irrigation _ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring 0Recovery ft. ft.
Injection Well:
ft. 1 ft. 1 Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable) -
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStorrnwater Drainage D ft. 44 ft t,Sand, Trermrrte
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) '�, • • '
FROM TO l DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) IOther(explain under#21 Remarks)
4t it.
Datit grey ash
4.Date Well(s)Completed:7-31-23 Well ID#DWI-21 5 ft. t 0 [t
pRadish brown sandy clay
5a.Well Location: 10 It 43 ft Dark grey ash
Duke Energy 43 ft 44 ft Native
Facility/Owner Name Facility ID#(if applicable) ft. ft. C .,,-,.1)
". .✓
ft. ft.
8320 NC 150, Sherrills Ford, 28673s
Physical Address,City,and Zip Ct. ft. , A U G 3 I 2OZ3
Catawba -21.REMARKS Irm o t:i-31�i -\
y`wgl:lt
County Parcel Identification No.(PIN) ' Ir'v O`Pi1c?
Sb.Latitude and longitude in degreesfminutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certification:e�
35.61599 N. 80.97861 w
7.zy-z y
6.Is(are)the well(s)rPermanent or IITemporary 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 E)No with 15A NCAC 02C.0100 or 1SA 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: 44 (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:
10.Static water level below topof casing: 14.5
(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:
(Le.auger,rotary,cable,direct push,etc.) I
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 t i 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