GW1--05660_Well Construction - GW1_20230831

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1' Print Form '
1.Well Contractor Information:
Nicholas Moreno -44.WATER ZONES = "'
Well Contractor Name FROM TO ft. DESCRIP I ON
4209-A ft I ft
NC Well Contractor Certification Number '15.OUTER CASING(for multi-cased'wells)OR LINER'(if applicable) •
"
Keller Industrial FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 16.INNERCASING 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. 16 ft- 4 ill Sch 40 rvc
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public 16 ft. 36 ft. 4 in. .20 Sch 40 Pvc
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT` `
Irrigation FROM .. TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery ft. ft. •
ft.Injection Well: ft. ,
, 1
Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) _
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage o ft- 36 ft- IA Send' Trentrme
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary) ,'
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
4 ft- 5 ft- Dafic grey ash
4.Date Well(s)Completed:8-1-23 Well ID#D W 1-26 5 ft. 10 IL p Redish brown sandy clay
5a.Well Location: ,o ft. 35 ft. Dark grey ash
Duke Energy 35 ft. 36 ft- Nativert.7 pe.17... f r r.7.3
Facility/Owner Name Facility ID#(if applicable) ft. ft. „ ' t k L`.,I L.& if 1-g..r
8320 NC 150, Sherrills Ford, 28673 ft. ft AUG 3 1 2073
Physical Address,City,and Zip R. tt. I
Catawba .21.REMARKS. ,. in,°^;n.ra i^(1 r• ;d -:•r4 i.:t;..L._
Dt IOJsum
County Parcel Identification No.(PIN)
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
..---0-- 7, o •77
6.Is(are)the well(s)°Permanent or Temporary S nature o 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 EiNo 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: 36 (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:
10.Static water level below topcasing: 14'8
of . (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 construction to the following:
12.Well construction method: _ f i
(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&Iniectionl 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