GW1--05683_Well Construction - GW1_20230831

f Print Form.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information:
Nicholas Moreno :14.-WATERZONES _"��;: a:
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
42Q9-A
ft. ft. 1 I
NC Well Contractor Certification Number i.15.OUTER'CASING(for multi-cased wells)OR:LINER(if op licable) __
Keller Industrial FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft. in.
Company Name ..16.INNER!CASING OR:TUBING(geotb'ermalclosed-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 avc
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN'. . _•;_ - . _
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 24 ft. 44 ft* 4 in.• 20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) ()Residential Water Supply(single) ft. ft. in.
Industrial/Commercial ()Residential Water Supply(shared) .18 GROUT,:_' -
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring r3Recovery ft. ft.
In
jection Well: ft. I fft. I 1 Aquifer Recharge ()Groundwater Remediation 19:°SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °StornwaterDrainage D ft. 44 ft. 1 A Sand Treavmte
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) Jig 1 Tracer 20.-DRILLING LOG attach additional-sheets if necessa _' * '`''', ':
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) o it. 5 u Dark grey ash
4.Date Well(s)Completed:7-19-23 Well ID#DWI-5 5 ft. 10 fL Radish brown sandy clay
5a.Well Location: ro ft. 43 ft. Dark grey ash .ti j.a fe"M,,,,1 It r.„i'"+t_
‘•��.e 6.....s m. L... .
Duke Energy 43 ft• 44 ft• Native ; 1
Facility/Owner Name Facility ID#(if applicable) ft. ft. 3 AUG 2023
8320 NC 150, Sherrills Ford, 28673 ft. ft. ,
Physical Address,City,and Zip bl vlr.;:sti:;1 �':'^.0;.'a:?:g t.:ti:r
ft. I cc I DWG
II. r-. `., V°' rt
Catawba -%.:V^- "'"
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.Certitieatio •
35.61599 N 80.97861 W
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6.Is(are)the well(s)DIPermanent or Temporary Si re 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 ONo 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 i
9.Total well depth below land surface: 44 (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 1Q100') construction to the following:
10.Static water level below topcasin • 14.2
of g• (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: +
(i.e.auger,rotary,cable,direct push,etc.) I
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&Iniectil n 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
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