GW1-2021-00898_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 wells OR LINER if a GcabIt
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#• WRO3001 15 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 0 ft. 57 ft. 6" 1O Schd 80 PVC
3.Well Use(check well use): ft. ft. in
Water Supply Well: FROMREE TO DIAMETER , SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 57 ft. 67 ft. 6" rn• .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 57 ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100000 GPD FROM I TO MATERIAL EMPLACEMENT M ETHOD&AMOUNT
Non-Water Supply Well: 0 ft• 51 ft. Neat Grout Tremie 150 Gallons
❑Monitoring I'Recovery 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 55 ft• 69 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 421 Remarks) FROM TO DESCRIPTION color,hardness soiltrock tyM grain size,etc.
0 ft• 10 ft• Not logged-Vacuum Utility Clearance
4.Date Well(s)Completed: 03/31/21 Well ID# EX-70 10 R. 20 ft• Clay
5a.Well Location: 20 ft• 60 ft. Sift
Allen Steam/Duke Energy N/A 60 ft• 76 ft• Bedrock
Facility/Owner Name Facility ID#(ifapplicable)
253 Plant Allen Road, Belmont, NC 28012
Physical Address,City,and Zip
Gaston 3592779998 2L REMARKS
County Parcel Identification No.(PIN)
t; rocessi►�g n
' � Secron
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 6 R
(if well field,one IatAong is sufficient) 22.Certification:
529454.7 N 1399285 Easting W Jon Keifer Jonlif-er 3116:03:oa 3/31/2021
6.Is(are)the well(s): [!]Permanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the ivell(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 ofthe 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 I 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: 76 (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 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 276 99-161 1
13s.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