GW1--05668_Well Construction - GW1_20230831

I Print Form :1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information: t
Nicholas Moreno 14.WATER-ZONES , -- - •
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4209-A
ft. I it. f
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased*ells)OR LINER(If ap licable) • :,
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. 26 ft. 4 In. Sch 40 avc
3.Well Use(check well use): ft. ft. In.
REE
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural °Municipal/Public 26 ft 46 ft. 4 in. .20 Sch 40 PVC
jig Geothermal(Heating/Cooling Supply) (°Residential Water Supply(single) ft. ft. in.
+Industrial/Commercial °Residential Water Supply(shared) ,IS.GROUT_
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
VI Monitoring °Recovery ft. ft.
Injection Well: 1
ft. I ft.
*Aquifer Recharge °Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
'*(Aquifer Storage and Recovery Ell Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
"Aquifer Test oStormwater Drainage 0 ft. 40 ft. 1,4 Sand ' Traimenir
if Experimental Technology *'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)
i n ft. 5 ft. Dark grey ash
4.Date Well(s)Completed:8-15-23 Well ID#DW2-7 5 ft. 10 ft. Redish brown sandy clay
5a.Well Location: is ft' 45 ft. Dark grey ash
re.
Duke Energy 45 ft as ft- liaise i �,, S \fF i":
Facility/Owner Name Facility ID#(if applicable) ft. ft.
8320 NC 150, Sherrills Ford, 28673 ft. ft. AVG a i 2023
Physical Address,City,and Zip ft. u. Ifh�rfVScz:t471 i�f.^.;.tr.1::;J Uri.
Catawba
County Parcel Identification No.(PIN)
5h.Latitude and longitude in degreest'minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification.
35.61599 N 80.97861 W
6.Is(are)the well(s)TjPermanent or Temporary tore o Certified Well Contractor Date
By signing this form,I hereby cent)'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or )No 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:
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: 46 (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'a (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 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: construction to the following:
(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&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. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016