GW1--05657_Well Construction - GW1_20230831

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information;
;
Nicholas Moreno -'14.WATER ZONES , ,
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
42Q9-A
rt. ft. I 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• 20 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 QMunicipal/Public 20 ft. 40 ft. 4 in' 1 .20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) ©1Residential Water Supply(single) ft. ft, in. '
Industrial/Commercial OResidential Water Supply(shared) GROUT18. '
Irrigation FROM , TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring EiRecovery ft. ft.
Injection Well:
ft. 1 ft. 1
Aquifer Recharge OGroundwater Remediation
.19.SAND/GRAVEL PACK(if applicable) ' -,- . - '
Aquifer Storage and Recovery EjISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStotmwater Drainage 0 ft• 40 ft• IA Sand , Trermrms •
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer -20.DRILLING LOG(attach additional sheets if necessary) = _ `-' LL'
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 9 ft. 5 ft. 'Dark grey ash
4.Date Well(s)Completed:8-1-23 Well II)#DWI-23 5 ft. 10 ft' Redish brown sandy clay
5a.Well Location: 70 ft• 38 ft. Dark grey ash
Duke Energy ES ft: 40 ft- Native
Facility/Owner Name Facility ID#(if applicable) ft. ft. p .171.11
e r--
8320 NC 150, Sherrills Ford, 28673 ft. ft. L
Physical Address,City,and Zipct. I +t, I AUG 3 1 2023
21.REMARKS. '..
Catawba
County Parcel Identification No.(PIN) - - - - - 1 Inl`cr>-afsc-n Prt..,r: ng Car,,#CJWCV- _- _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(if well field,one lat/long is sufficient) 22.Certifcatio
35.61599 N 80.97861 N,
ZO •Z3
6.Is(are)the well(s)DPermanent or !Temporary rgnahrre of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or )No with 15A NCAC 02C.0100 or 15A 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#2I 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: 40 (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@I00') construction to the following: I,
10.Static water level below top of casing: 15.7 (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
(i.e.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 to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016