GW1-2021-00896_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 mulfi-cased wells OR 11NER if a Gcable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM To DIAMETER THICIavESs MATERIAL
ft. % I in.
Company Name
��/p 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#' V�R03001 15 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 0 ft. 140 ft. 6° ra Schd 80 PVC
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.FROMSCREE TO DIAMETER � SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 140 ft. 150 ft. 6" irL .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) It- 140 ft-
0 Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It• 136 It. Neat Grout Tremie 150 Gallons
❑Monitoring InRecovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMEPHOD
❑Aquifer Test ❑StonnwaterDrainage 138 It. 152 ft- #2 Filter Sand ITremie
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiufock
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) grain size,etc.
0 ft. 10 ft. Not logged-Vacuum Utility Clearance
4.Date Weli(s)Completed: 03/31/21 Well ID# EX-55 10 ft. 60 ft- Sand
5a.Well Location: 50 It' 120 It' Sift
Allen Steam/Duke Energy N/A 120 It• 148 ft. Sand
Facility/Owner Name Facility ID#(ifapplicable) 148 ft• 152 It. Weathered Rock E`l
253 Plant Allen Road, Belmont, NC 28012 ft. rt.
Physical Address,City,and Zip ft. ft. 1
Gaston 3592779998 21.REMARKS
County Parcel Identification No.(PIN) uIlit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ct�'3I�3 P SEvron
(if well field,one lat/long is sufficient) 22.Certification:
524940.1 N 1400502 Easting w Jon Keifer Jon liter
2021-03-3115:17:50 3/31/2021
6.Is(are)the well(s): [!]Permanent 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 InNo 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 921 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: 152 (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 1 7
If water 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 OpenLoop 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 Girl):Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13b.Disinfection type: Amount:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018