GW1--05664_Well Construction - GW1_20230831

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: . r---
Nicholas Moreno :14.WATERZONEs ,.,
FROM TO DESCRIPTION
Well Contractor Name
ft. ft. l
4209-A ft. I ft. I r
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased-wells)OR LINER(if ap licable)
Keller Industrial FROM TO DIAMETER • THICKNESS 1 MATERIAL
It. 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• 27 ft• 4 , In. Sch 40 PVC
3.Well Use(cheek well use): ft. ft. is
:17..SCREEN, ' -
'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural oMunicipal/Public 27 ft. 47 ft. 4 in.' .20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) EllResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT _ 1 - I - '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery ft. ft.
Injection Well: I ft. 1
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)- ' ...
Aquifer Storage and Recovery ©I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test X+StortawaterDminage o ft• 47 ft. PA Sand Treannie
Experimental Technology i*+Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer -20.DRILLING LOG(attach additional sheets if necessary);-., ' . ,
FROM TO DESCRIPTION(color,hardness,sail/rack type,grain size,etc.)
_ Geothermal(Heating/Cooling Return) 010ther(explain under#21 Remarks)
tt 5 R- Dan grey ash
4.Date Well(s)Completed:7-20-23 Well ID#DW1-3 5 ft• 10 ft Redish brown sandy clay
5a.Well Location: 'a ft. 45 ft' Dark grey ash
Duke Energy 45 it 4r fa Native s,: -, :;1,l{
Facility/Owner Name Facility ID#(if applicable) ft. ft. iX C 1.'.a ,`9 3....eel
8320 NC 150, Sherrills Ford,28673 ft. ft. AUG 3 1 2023
Physical Address,City,and Zip it. ft' ;
2L REMARKS'. , - itt+ui4`r,a*' ,,• • C " ,•�%^- -
Catawba •
Cj�'di Y�l�w
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certiticatio •
35.61599 • N 80.97861 w -
6.Is(are)the well(s)0Permanent or MiTemporary
Si lure of Certified 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 Elm. with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill 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: 47 (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: 14'2 (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:
(Le.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&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