GW1-2021-00916_Well Construction - GW1_20210402

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jon Keifer 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NCWC 4097-A ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells O- LINER if a Gcable
Landprobe, Dept. of Bunnell Lammons Eng. FROM To DIAMETER TxICIavFss MATERIAL
ft. ft. in.
Company Name
WR0300115 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. 52.5 ft. 6" 1° Sehd 80 PVC
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 58.5 ft- 68.5 ft' 6 in. .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft- 58.5 ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) HL
18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 55 fit- Neat Grout Tremie 150 Gallons
❑Monitoring IlRecovery ft. ft.
Injection Well:
ft. k.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 56.5 "' 69 ft- #2 Filter Sand Tremie Sand
❑Experimental Technology ❑Subsidence 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 DESCRIPTIONcolor hardness soillrock tym orain size,etc.
0 ft. 10 ft• Not logged-Vacuum Utility Clearance
4.Date Well(s)Completed: 03/31/21 Well ID# EX-3 10 ft- 20 ft. Silt
5a.Well Location: 20 ft' 30 ft. Clay
Duke Energy, Allen Stearr N/A 30 ft• 43 ft. Silt
Facility/Owner Name Facility ID#(ifapphcable) 43 "' 53 ft. Sand
253 Plant Allen Road, Belmont, NC 28012 53 ft. 69 ft. Gravel
Physical Address,City,and zip 60 ft• 78 ft. Bedrock 95�
Gaston 3592779998 21.REMARKS o
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/Iong is sufficient) 22.Certification:
529451.8 N 1400701 Easting w Jon Keifer Date:2o2go�;y,8°�5Be04'oo' 3/31/2021
6.Is(are)the well(s): nPermanent or ❑Temporary Signature of Certified Well Contractor Date
Bysigning this form,I hereby certi that the well(s)was(were)constructed moccordance with
7.Is this a repair to an existing well: ❑Yes or ONO 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthts 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 construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 78 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 a 00'and 1@I00�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 10 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method Rita'7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh;NC 276 99-16 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018