GW1-2021-00888_Well Construction - GW1_20210402

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jon Keifer 14.WATER ZONES
TO
Well Contractor Name FROM 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 THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal 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. 114 ft. 6" In. SChd 80 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: lF7R.OM REE TO DIAMETER F SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 114 ft. 124 ft. 6" im .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft- 114 ft. m
❑Industrial/Commercial ❑Residential Water Supply(shared) Is.GROUT i
❑Irri ation ❑Wells>100000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f1• 106 ft• Neat Grout Tremie 150 Gallons
❑Monitoring nRecovery 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 ❑StormwaterDrainage 110 ft• 125 ft• #2 Filter Sand Tremie
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
type,a
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTIONcolor,hardness,soil/rockrain size,etc.
0 ft. 20 ft. Not logged-Vacuum Utility Clearance
4.Date Well(s)Completed: 03/31/21 Well ID# EX-16 20 ft- 58 ft. Sift
5a.Well Location: 58 ft' 124 ft. Sand
Allen Steam/Duke Energy N/A 124 n- 130 rt. Bedrock
Facility/Owner Name Facility ID#(if applicable) ft. ft.
253 Plant Allen Road, Belmont, NC 28012 ft. ft.
Physical Address,City,and Zip ft. ft. �IPR
Gaston 3592779998 21.REMARKS it
on Pr^cessln
County Parcel Identification No.(PIN)
rat
D1r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification:
529052 N 1399083 Easting w Jon Keifer Jon 1,ifer
2021-03-3115:13:43 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 ONo 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 Ici 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: 130 (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 a 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 27699-1617
If water level is above casing,use•'+"
11.Borehole diameter: 10 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: R©ta'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 27699-16 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018