GW1--05682_Well Construction - GW1_20230831

I:Print Form,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: !
Nicholas Moreno 14.WATER ZONES . .
Well Contractor Name FROM TO DESCRIPTION
ft. ft. l
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 g MATERIAL
ft.. ft. I I 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. 20 ft. 2 1n. Sch 40 pvc
3.Well Use(check well use): ft. it in.
Water Supply Well: • FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 20 ft' 40 ft' 2 id. .20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT - '` '
Irrigation FROM TO , MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. ,
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
'•19:SAND/GRAVEL PACK(if applicable)- '
Aquifer Storage and Recovery - Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStcxmwwter Drainage D n• 40 ft• as send Trerrrrrie
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) EllTracer 20.DRILLING LOG(attach additional sheets if necessary):
FROM 1 TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
O CA• 5 St• Dahc grey ash
8-16-23 DOW-6 it. ft
4.Date Well(s)Completed: Well ID# s t 0 Redish brown sandy day ,„,, / :
5a.Well Location: is ft. 38 ft. Dark grey ash )s.)`� A T,,..a
Duke Energyr
40 IL Native 1, 2423
Facility/Owner Name Facility ID#(if applicable) ft. ft. AU U t lf'
8320 NC 150, Sherrills Ford, 28673 ft. ft. ?.r t-, "
Physical Address,City,and Zip ft. 1 tt, l 1[ �"' pIc ' Afa A%'
Catawba 2i: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.Certifies
35.61599 N 80.97861 W
or 2iTemporary Signature of Certified Well Contractor Date
6.Is(are)the well(s)DPermanent
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 EiNo with 1SA 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: 40 (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: '
'
14.9
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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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.) 1
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServiceiC,nter,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-I North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016
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