GW1--05681_Well Construction - GW1_20230831

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information:
'
Nicholas Moreno 1a.WATERZONEs'..
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4209-A
ft. ft.
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.U1C,County,State,Variance,etc.) 0 ft. 26 ft. 2 I in' Sch 40 PVC
3.Well Use(check well use): ft. ft. in
Water Supply Well: FRO SCREENF TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
Agricultural IOMunicipal/Public 26 ft. 46 ft' 2 in: .20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial II'Residential Water Supply(shared) 18.GROUT r
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring EiRecovery ft. ft. 1
ft. 1 •
Injection Well: tt
Aquifer Recharge DGroundwater Remediation '
19.SAND/GRAVEL PACK(if applicable) '
Aquifer Storage and Recovery ED Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStortawwaterDrainage o ft• 1 46 ft. 1ASend Treaxniw
Experimental Technology MI Subsidence 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,soiVrock type,grain size,etc.)
R it. Dark grey esYi
4.Date Well(s)Completed:8-16 Well1D#DOW-5 5 ft. 10 ft. Radish brown sandy clay
5a.Well Location: 10 ft* 45 ft' Dark grey ashy y+ J � �� �•
_ �inis.
Duke Energy as fL 46 ft Native, � 24't'3
Facility/Owner Name Facility ID#(if applicable) ft. ft. Aii(a tt ttn;
8320 NC 150, Sherrills Ford, 28673 ft. ft. �,. ?r.� i-
,
-1
Physical Address,City,and Zip ft. tt 1th�•'f• ��+�'�v
Catawba 21.REMARKS
County Parcel Identification No.(PIN)
'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifrcati
35.61599 N 80.97861 Nr
7ZU•77
6.Is(are)the well(s)rjPermanent or ltTemporary Signature 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 ElNo 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:
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: j,
10.Static water level below top of casing: 15.1 (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: 24a 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 io the county health department of the county
where constructed. I
I 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016