GW1--05659_Well Construction - GW1_20230831

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: " "
J.Well Contractor Information:
Nicholas Moreno ;1a:wATEltzor s ,,:
Well Contractor Name FROM TO DESCRIPTION
ft. ft. I '
4209-A
ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(f applicable)
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. .15 ft. 4 . in. Sch 40 cvc
3.Well Use(check well use): ft. ft. in.
17.SCREEN. - •
Water Supply Well: FROM TO DIAMETER• SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public _ 15 ft. 35 ft. 4 in. .20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft. in.
Industrial/Commercial *iResidential Water Supply(shared) 18.GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring 0Recovery ft. ft. 1
Injection Well: ft. ft.
Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)'
Aquifer Storage and Recovery °°Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage 0 ft• I 355 ft. to Sand Treteme
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG:(attach additional sheets if necessary): ".
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) v [t. s tt. Dark grey ash
4.Date Well(s)Completed:8-1-23 Well ID#DWI-25 5 ft. 10 tt
pRedish brown sandy clay
5a.Well Location: ,o ft. 34 it. Dark grey ash
Duke Energy 34 it. 35 !t: Native ;
Facility/Owner Name Facility ID#(if applicable) p`
ft. ft. ! 1' .t�;1tY.:i'�F L ij
8320 NC 150, Sherrills Ford,28673 ft. ft.
Physical Address,City,and Zip
ft- 1 ft. I AUG 3 1 2023
Catawba 21 REMARKS = ,
County Parcel Identification No.(PIN) DAPoClSl a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification
35.61599 N 80.97861 W
7,76 . Z3
6.Is(are)the well(s)rjPermanent or Temporary S' are of citified 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 jNo with ISA 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#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: 35 (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 2Qa 100') construction to the following:
10.Static water level below to of casin 15.0
P g� (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
t
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 tliis;form within 30 days of completion of well
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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