GW1-2021-00889_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. It.
NCWC 4097-A ft. %
NC Well Contractor Certification Number 15.OUTER CASING for multsed wells OR LINER if a ticable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM To DIAMETER THIclavEss MATERIAL
ft. ft. I in.
Company Name
16.INNER CASING OR TUBING eothermal 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 ft- 115 ft- 6° rn Schd 80 PVC
3.Well Use(check well use): ft. ft.17.
is
Water Supply Well: FROM EE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 115 ft. 125 It' 6° im .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft• 115 ft. '°
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 111 ft• Neat Grout Tremie 150 Gallons
❑Monitoring I'Recovery
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 113 ft. 130 ft- #2 Filter Sand JTremie
❑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/mck type,grain size,etc.
0 ft- 20 ft. Not logged -Vacuum Utility Clearance
4.Date Well(s)Completed: 03/31/21 Well ID# EX-1 8 18.5 ft• 40 "L Silt
5a.Well Location: 40 ft• 80 & Sand
Allen Steam/Duke Energy N/A 80 ft• 115 ft. Weathered Rock
Facility/Owner Name Facility ID#(ifapplicable) 115 ft. 130 ft- Bedrock B `' d
253 Plant Allen Road, Belmont, NC 28012 ft. ft.
Physical Address,City,and Zip ft. ft. AP
Gaston 3592779998 21.REMARKS 8 CC`c�` ' nit.
County Parcel Identification No.(PIN) IPi�0IP3tivll
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
528898.3 N 1399242 Easting w Jon Keifer Jon leilr
2021-03-3115:11:22 3/31/2021
6.Is(are)the well(s): MPermanent 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 [INo I5A NCAC 02C.0100 or 15A NCAC 01C.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: 130 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths rf different(example-3 rr 00'and 1@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
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
Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources) Revised 6-6-2018