GW1--05675_Well Construction - GW1_20230831

Ill ,Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Nicholas Moreno -14.WATER ZONES -. ..„.t'
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`licable).
Keller Industrial FROM TO DIAMETER THICKNESS 1 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(Le.UIC,County,State,Variance,etc.) 0 ft 24 ft 4 ' in' Sch 40 rvc
3.Well Use(check well use): ft. ft. is
Water Supply Well:
17:;SCREEN -..
pp y FROM TO cDIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 24 ft 44 ft. 4 In.` .20 Sch 40 pvC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft. in.:
Industrial/Commercial jResidential Water Supply(shared) r r
i Irrigation FROM TO n ~MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring ORecovery ft. ft.
Injection Well: ft. ft. 1
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable) -= '" . '"
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test - OStorcnwater Drainage 0 ft. 44 ft IA Send Tremmle
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer '20:-DRILLING LOG(attach additional sheets if necessary),'
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rock type Brain size etc.)
t7 EL 5 Dade grey ash
4.Date Well(s)Completed:7-19-23 Well ID#DWI 5 ft. 10 it Radish brown sandy clay
5a.Well Location: 1D ft• 43 ft Dark grey ash P I;.. "w..,y i i-..�.r
Duke Energy 43 ft- ' 44 ft Realm • " %a...,, IL.i ►!" !
Facility/Owner Name Facility ID#(if applicable) ft. ft. AUG 3 I 2023
8320 NC 150, Sherrills Ford, 28673 ft. ft.
Physical Address,City,and Zip it„;,c„,s;t�;l f;:?:.,x•►v:rJ(,�ti
cc, l St. l DWC MOi
Catawba 21:REMA1uKS i,,,-A' e, 7.. ..: . ,.. .'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r r
(if well field,one lat/long is sufficient) 22.Certiticati0 •
35.61599 N 80.97861 W
%- ao •z 3
6.Is(are)the well(s)ljPermanent or MI Temporary Si tore 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: DYes or MNo 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'
44
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2(41100) construction to the following: i
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 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: I 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. )
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016