GW1-2021-00890_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 livable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. PROM TO DIAMETER TxICIINEss MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WR03001 15 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) 0 ft. 98.5 ft' 6" rn Schd 80 PVC
3.Well Use(check well use):
tt. ft, in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 98.5 ft' 108.5ft• 6" 'n' .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 98.5 fr. fn
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100000 GPD FROM I TO MATERIAL EMPLACEMENT METH OD&AMOUNT
Non-Water Supply Well: 0 f` 93.7 fl- Neat Grout Tremie 150 Gallons
❑Monitoring (tRecovery 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 98.5 ft. 108.5 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 tinder#21 Remarks) FROM TO DESCRIPTION color,hardness soil/ ck 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 9 20 fr• 40 ft- Not logged-No Recovery(20'-29'),Silt(29'-40')
5a.Well Location: 40 ft' 60 ft. SIR
Allen Steam/Duke Energy N/A 60 ft. 80 ft. Sand
Facility/Owner Name Facility ID#(if applicable) 80 ft. 100 ft. No Recovery ,ram i
253 Plant Allen Road, Belmont, NC 28012 99.5 fr. 108.5 ft- Weathered rock`
Physical Address,City,and Zip 108.5 ft. 115.1 ft. Bed rock
Gaston 3592779998 21.REMARKS
County Parcel Identification No.(PIN) 11
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
dwell field,one lat/lon is sufficient Y
C d 8 ) 22.Certification:
528807.9 N 1399332 Easting W Jon Keifer Jon lifer
2021 03-3116:13:23 3/31/2021
6.Is(are)the well(s): IlPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certtfy 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.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 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: 115.1 (ft)
For multiple wells list al/depths if different(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
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
Ifwaler 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: 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 27699-1611
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