GW1-2021-00891_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 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased weUS)OR L[NER if a ►icable
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#: WR03001 15 FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 0 ft. 78_55 ft- 6" 1D Schd 80 PVC
3.Well Use(check well use): ft. fr. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 78 5 ft• 88.5 ft. 6" im .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft- 78 5 ft. 1O
❑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 f`' 69.5 ft• Neat Grout Tremie 150 Gallons
❑Monitoring CJRecovery tt. 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 ❑Storm water Drainage 78.5 ft• 88.5 f`' #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,soiUmck type,grain size,etc.
0 ft. 20 ft. Not logged-Vacuum utility Clearance(0'-1 0),No Recovery(10'-20')
4.Date Well(s)Completed: 03/31/21 Well ID# EX-20 20 ft. 60 ft. Sift
5a.Well Location: 60 f` 80 f` Weather Rock
Allen Steam/Duke Energy N/A 80 f` 90.3 f` Bedrock
Facility/Owner Name Facility tD#(ifapplicable) ft. ft. .�
253 Plant Allen Road, Belmont, NC 28012 ft. ft.
Physical Address,City,and Zip fr. ft' AP
Gaston 3592779998 21.REMARKS l 't
County Petrel Identification No.(PIN) 1it�ll� t10I11 j`^ .n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
528710.1 N 1399432 Easting W Jon Keifer Jon Kilr
2021-03-3116:14:40 3/31/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 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':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: 90.3 (fL)
For multiple wells list all depths if different(example-J r200'and 2 a@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 2 7699-16 17
Ifwater level is above casing,use
It.Borehole diameter•' 10 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method: Rota'] 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
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