GW1--05676_Well Construction - GW1_20230831

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WELL CONSTRUCTION RECORD(GW-1) ' For Internal Use Only:
1.Well Contractor Information: t ;
li
Nicholas Moreno 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
' ft. ft
4209-A
rt. ft. 1 1 I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)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. 16 ft 4 in. Sch 40 PVC
-
3.Well Use(check well use): ft. ft. In.
17:SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public 16 ft• 36 ft. 4 In. .20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in. .
Olndustrial/Commercial (°Residential Water Supply(shared) 18 GROUT
fli rigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
°Monitoring °Recovery ft. ft.
Injection Well:
ft. I ft.
.3Aquifer Recharge (°Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) '
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwaterDtainage 0 ft. 36 ft to sand Trermrrre
Experimental Technology 0 Sub sidence Control ft. ft
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary) ,'
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soi/rock type grain size,etc)
9 tt 5 ;t' Dark grey ash
4.Date Well(s)Completed:8-16-23 Well lD#DW2-14 5 ft. 10 ft Redish brown sandy clay
5a.Well Location: iu it 35 ft Dark grey ash
Duke Energy 35 ft- ss ft Native EF F(T''t" "i r1"�
Facility/Owner Name Facility 1D#(if applicable)
ft. ft y 4�k,�
8320 NC 150, Sherrills Ford, 28673 ft. ft. AU6 3 1 ZUZ3
Physical Address,City,and Zip Q. ft I lrifmro-vca4irv0 Pr r�An31lily
Catawba •;21:,REMARICS.. . - ._ Ctt.,e:,,r.1n .<
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1aUlong is sufficient) 22.Certification:
35.61599 N 80.97861 W
7Z6 -Z7
6.Is(are)the well(s)iPermanent or [Temporary rgnature of Certified Well Contractor Date
By signing this form,I hereby certi y that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or a No with ISA NCAC 02C.0100 or 1SA 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 i
9.Total well depth below land surface: 36 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diffrent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 3'9_ (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 form within 30 days of completion of well
12.Well construction method: construction to the following: '
(ie.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&Iniection 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-I North Carolina Department of Environmental Quality-Division of Water Resources ( Revised 2-22-2016