GW1-2021-00886_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
ft. ft.
NCWC 4097-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM TO DIAMETER THICIavFss MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WR03001 15 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State, Variance,etc) 0 ft. 56 ft. 611 rn I Schd 80 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 56 ft. 66 ft' 6" im .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 56 g ;n
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
❑Irri ation ❑Wells>100000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 49 ft- Neat Grout Tremie 150 Gallons
❑Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 53 ft' 67 ft. #2 Filter Sand ITremie
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if accessory)
FROM TO DESCRIPTION color,hardness,soil/rock
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) rain sue,etc.
0 It. 10 ft- Not logged-Vacuum Utility Clearance
4.Date Well(s)Completed: 03/31/21 Well ID# EX-14 10 " 30 "- No Recovery
5a.Well Location: 30 ft. 60 ft. Silt
Allen Steam/Duke Energy N/A 60 fr 67 ft• Bedrock g
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
253 Plant Allen Road, Belmont, NC 28012 ft. ft.
Physical Address,City,and Zip ft. ft.
Gaston 3592779998 21.REMARKS n Prnrnssing
County Parcel Identification No.(PIN) DWR Sedan
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
529296.4 N 1399403 Easting w Jon Keifer Jon Keifer
2021-03-3115:56:37 3/31/2021
6.Is(are)the well(s): IlPermanent 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 ONo 15ANCAC 02C.0100 or 15A NCAC 02C.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 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 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: 67 (ft) 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@100')
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 2 7699-16 17
Ifwater level is above casing,use"+"
11.Borehole diameter: 10 (in,) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(NC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary 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
13a.Yield(gP m) Method of test: Permit Program,1611 MSC,Raleigh,NC 276 99-161 1
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13b.Disinfection type: Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018