GW1--05661_Well Construction - GW1_20230831

T Print Form 4 j
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
I.Well Contractor information:
Nicholas Moreno 14 WATER ZONES -. `- '
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"licablc)'
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. 11 ft 4 in. Sch 40 PVC
3.Well Use(check well use): ft. ft. is
17.SCREEN .
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural oMunicipal/Public it ft- 31 ft. 4 ►n•' .20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft ft. in.
Industrial/Commercial IDResidential Water Supply(shared) 18.GROUT -'--
Irrigation FROM TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring ORecovery ft. ft. .
Injection Well:
ft I ft. I 1
Aquifer Recharge IDGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable) , . ..
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStermwaterDrainage o ft• 31 ft• )A Sand' Treinme
Experimental Technology DSubsidence Control ft. ft. ,
Geothermal(Closed Loop) 101Tracer 20.DRILLING LOG(attach additional sheets if necessary) '•
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Geothermal(Heating/Cooling Return) InOther(explain under#21 Remarks)
9 St, '6 ft- Data grey ash
4.Date Well(s)Completed:8-7-23 Well ID#DW2-1 5 ft. 10 ft Redish brown sandy clay
5a.Well Location: 'o ft. 30 ft Dark grey ash
Duke Energy 30 ft 31 ft- Native/Nock
Facility/Owner Name Facility ID#(if applicable) ft. ft y ,j-r-1• •r..
8320 NC 150, Sherrills Ford,28673 rt. ft.
Physical Address,City,and Zip cu I cc. 1 A U G 3 1 2023
Catawba
Irri rR,aUcr1 P "5 ;`e.-2 Un,ii
County Parcel Identification No.(PIN) Dt Y` JO7
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 22.Certif ratio .
35.61599 N 80.97861 W
. 7,Z 0 ,'Z 3
6.Is(are)the well(s)TjPermanent or Temporary gnature 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: JYes or 11?)/4. 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#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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: 31 (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: 13'9 (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 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
I
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 tbi the county health department of the county
where constructed. l
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016