GW1-2021-00900_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 livable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM To DIAMETER THICKNESS MATERIAL
ft. ft, 1 in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#' WR03001 15 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) 0 e' 65 rt. 6 'n' Schd 80 PVC
3.Well Use(check well use): ft. ft in.
17.
Water Supply Well: FROMREE TO DIAMETER SLOT SITE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 65 ft' 75 fit' 6" in. .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 65 ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 e• 58 ft. Neat Grout Tremie 180 Gallons
❑Monitoring In Recovery
Injection Well:
ft. tt.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stonnwater Drainage 63.5 rt• 77 rc• #2 Filter Sand JTremie
❑Experimental Technology ❑Subsidence Control ft. R.
❑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,wiltrucktype,grain size etc.
0 rr• 10 rr• Not logged-Vacuum Utility Clearance
a.Date Well(s)Completed: 03/22/21 Well ID# EX-76 10 ft. 15 ft. Clay
5a.Well Location: 15 ft' 37 ft. Silt
Allen Steam/Duke Energy N/A 37 rt• 74.5 It. Sand
Facility/Owner Name Facility ID#(ifapplicable) 74.5 e' 87 ft. Bedrock
253 Plant Allen Road, Belmont, NC 28012 ft. ft. t
Physical Address,City,and Zip ft. ft.
Gaston 3592779998 21•REMARKS it
r.". , lien Pr^� es.s►
County Parcel Identification No.(PIN) ,• '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) 22.Certification:
529856.5 N 1400337 Easting w Jon Keifer Dae:2029o322084s20-040o' 3/22/2021
6.Is(are)the well(s): C1Permanent 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 15ANCAC 02C.0100 or 15A NCAC 01C.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 I GW-I 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: 87 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 a200'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 76 99-16 17
Ifwater level is above casing,use"+"
11.Borehole diameter: 10.1 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(NC)
p } 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
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018