GW1--05687_Well Construction - GW1_20230831

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: r t
I I
Nicholas Moreno .14:WATER ZONES. . - ram , _- : 3 . .. . . .,_
Well Contractor Name FROM TO DESCRIPTION
ft. ft. I
42Q9-A ft. ft. I I
NC Well Contractor Certification Number .j5,OUTER CASING(for'multi-cased wells)ORLINER;(ifap licalilef .?,, ,' <`_'
Keller Industrial FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. ! in.
Company Name
u:16INNER:CASING.OR,TUBING.(geoth'ermal closed-tuop)i; ..r V, «„_.
2.Well Construction Permit#: FROM. TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 27 ft• 4 i in' Sch 40 PVC
3.Well Use(check well use): ft. ft. , in.
Water Supply Well: 17'SCREEN,. ._ z> n
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 27 ft. 47 ft. 4 inl .20 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in;
Industrial/Commercial OResidential Water Supply(shared) IS:GROUT, ,. k_ ". 3
1 Irrigation FROM TO MATERIAL' , EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. i
Monitoring E3Recovery ft. ft.
Injection Well: ft. I ft. 1
Aquifer Recharge IDGroundwater Remediation
fig:SAND/GRAVEL PACK(if appliealile)_, . =. .:� ...1`= .
Aquifer Storage and Recovery jI Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStorntwater Drainage o ft• 47 ft• 1ASand! Tterrnm'v
Experimental Technology 0 Subsidence Control ft. ft. i
Geothermal(Closed Loop) it Tracer 10.'DRILLING`I OG(att'ach additioriai sheets if necessary`Ps-, 5. r .
size FROM I TO DESCRIPTION(color,hardness, etc.)sol
Geothermal(Heating/Cooling Return) fl Other(explain under#21 Remarks) Urock type,grain
4 ff- 5 it- Daft grey ash
4.Date Well(s)Completed:7-21-23 Well ID#DWI-9 5 ft. 10 ft* Radish ti'rown sandy day
5a.Well Location: 70 it 45 ft. Dark grey ash
Duke Energy 45 ft 4r ft• Native '
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1 i� 2"..q`"" Oy
8320 NC 150, Sherrills Ford,28673 ft ft t1 }'r
Physical Address,City,and Zip it. 1t' l AU(I+ 3 1 2 V 2
Catawba 11:=REMARKS .' ., ... ,,.A x 1 ..:`
11401 art P . 4 Unit
County Parcel Identification No.(PIN) j)W Q C.14.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(if well field,one lat/long is sufficient) 22.Certificatio
35.61599 N 80.97861 W
7•Zta -z7
6.Is(are)the well(s)OPermanent or IffilTemporary Si cure 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 X)No 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.
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repair under#2I 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 pageIto.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: 1
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 47 (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: I
10.Static water level below top of casing: 15.1 (ft.) Division of Water Reso 4rces,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 Iniection 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: J 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. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016