GW1-2021-00899_Well Construction - GW1_20210402

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jon Keifer 14.WATER ZONES
FROM TO I 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 livable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROMTO
DIAMErER TxICKNEss MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• WR0300115 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 0 ft. 30.5 ft. 611 rn. Sehd 80 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30.5 tt• 40.5 ft' 6" 1- .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) It- 30.5 ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑bri ation ❑Wells>100000 GPD FROM I TO MATERIAL EMPLACEMENT MEI'HOD&AMOUNT
Non-Water Supply Well: 0 ft- 23 ft. Neat Grout Tremie 150 Gallons
❑Monitoring LiRecovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 28.5 " 42.5 ft• 1#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,soillrock type,grain sae,etc.
0 It. 10 It. Not logged-Vacuum Utility Clearance
4.Date Well(s)Completed: 03/31/21 Well ID# EX-75 10 R' 20 tr• No Recovery(1U-135),Clay(13.5'-15),Silt(15'-20')
5a.Well Location: 20 tt. 40 ft. Sand
Allen Steam/Duke Energy N/A 40 e• 49.9 tt• Bedrock
Facility/Owner Name Facility m#(if applicable) ft. ft. p�
253 Plant Allen Road, Belmont, NC 28012 ft. ft.
Physical Address,City,and Zip
Gaston 3592779998 21.REMARKS
County Parce I Identification No.(PIN) + n06SSln0l)tSlt
e„ron
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �'JR S ^
(if well field,one lat/long is sufficient) 22.Certification:
529640.8 N 1399893 Easting W Jon Keifer Jon lifer
2021-03-3115:52:33 3/31/2021
6.Is(are)the well(s): InPermanent 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 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:49.9 (ft)
For multiple wells list all depths if different(example-3 a 00'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+
It.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 276 99-16 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
i
Fortn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources- Revised 6-6-2018