GW1--05662_Well Construction - GW1_20230831

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Nicholas Moreno -14.WATER ZONES l;s
FROM TO DESCRIPTION
Well Contractor Name I ,
ft. ft.
4209-A ft ft. i
NC Well Contractor Certification Number -15.OUTER CASING;(for multi-cased wells)OR LINER(if'apelicable)
Keller Industrial FROM TO DIAMETER THICKNESS I 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 avc
3.Well Use(check well use): ft. ft. In.
Water Supply Well:
Pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public 15 ft. 35 ft. 4 in. .20 Sch 40 Pvc
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft it. in.
X Industrial/Commercial EIResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery ft. ft.
Injection Well:
ft 1 ft.
Aquifer Recharge EiGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)' '
Aquifer Storage and Recovery i,'Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStorrnwater Drainage 0 ft. .75 ft• 'tASend Trenrale
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OlTracer -20.DRILLING LOG.(attach additional`sheets if necessary) - ,.,
FROM I TO DESCRIPTION(color,hardness,solUrock type,grain
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) size,etc.)
q ft. 5 R- Dark grey afn
4.Date Well(s)Completed:8-7-23 Well ID#DW2-2 5 [t. 10 ft* Redlsh brown sandy clay
5a.Well Location: to ft' 34 ft' Dark grey ash
Duke Energy 34 ft 35 ft Native 'E.%/�:"-a
Facility/Owner Name Facility ID#(if applicable) ft. ft. 4 4...,),
8320 NC 150, Sherrills Ford, 28673 ft. ft. AUG 3 1 1023
Physical Address,City,and Zip ft ft' i fli` illlaUc n P'' r c'.a n,-,s r r
Catawba =21.REMARKS:'; ':, 1)INtl,nr,• , Za
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(if well field,one let/long is sufficient) 22.Certificatio •
35.61599 N 80.97861 W
-sue- ?•20 '07
6.Is(are)the well(s)DPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certiti that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ONo 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 2@100) construction to the following:
10.Static water level below top of casing: 14.3 (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 (m-) 24b.For Infection 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:
(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&Infection 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. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Reaourcesl Revised 2-22-2016