GW1-2021-00927_Well Construction - GW1_20210402

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jon Keifer 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
NCWC 4097-A
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eother at closed-loop)
2.Well Construction Permit#: M03001 15 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 It. 53 ft. 6" rn Schd 80 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 53 ft. 63 f" 6„ in .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft- 53 ft- in
❑industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑Irri ation ❑Wells>100000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt• 46.3 ft. Neat Grout Tremie 150 Gallons
❑Monitoring ORecovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Test ❑Stormwater Drainage 50.7 ft. 64 ft. #2 Filter Sand Tremie
❑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 DESCRIPTION color,hardness,soil/rock type grain size,etc.
0 ft. 10 ft- Not logged-Vacuum Utility Clearance
4.Date Well(s)Completed: 03/31/21 Well ID# EX_9 10 ft. 20 ft. Clay
5a.Well Location: 20 ft. 30 ft. No recovery t�
Allen Steam/Duke Energy N/A 30 ft' 63.5 ft. Sand
Facility/Owner Name Facility ID#(ifapplicable) 63.5 ft' 65 ft- Bedrock 02
253 Plant Allen Road, Belmont, NC 28012 ft. ft. it
Physical Address,City,and Zip ft. ft. {OI Bt',OI1 1?
Gaston 3592779998 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatflong is sufficient) 22.Certification:
529472.8 N 1399970 Easting w Jon Keifer Jon 11r
2021-03-3115:55:42 3/31/2021
6.Is(are)the well(s): nPermanent or ❑Temporary Signature of Certified well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis 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-1 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: 65 (fo Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 200'and 2@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(fUQ
12.Well construction method: RDta'7
Program,1636 MSC,Raleigh,NC 27699-1636
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 27699-1611
13s.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
I
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018