GW1-2021-00902_Well Construction - GW1_20210402

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jon Keifer 14.NVATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
NCWC 4097-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Gcable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM To DIAMETER THIclavFss MATERIAL
ft. % I in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
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 ft. 68 ft. 6�1 ra Schd 80 PVC
3.Well Use(check well use): ft. tt. in.
17.
Water Supply Well: FROM SCREEN
TO DIAMETER c' SLAT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 68 ft. 78 it. 6 1- .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr, 68 g• in.
❑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 ft 50 ft Neat Grout Tremie 150 Gallons
❑Monitoring nRecovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
[]Aquifer Test ❑Stormwater Drainage 54 ft' 68 tL #2 Filter Sand Tremie
❑Experimental Technology ❑Subsidence Control
❑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 soil/rock type,grain size,etc.
0 ft. 10 ft- Not logged -Vacuum Utility Clearance
4.Date Well(s)Completed: 03/31/21 Well ID# EX-84 10 ft• 30 it- No Recovery
5a.Well Location: 30 tt• 40 ft- Clay
Allen Steam/Duke Energy N/A 40 ft' 55 1 Sand
Facility/Owner Name Facility ID#(ifapplicable) 55 ft- 76 ft- Weathered Rock
253 Plant Allen Road, Belmont, NC 28012 76 ft• 80 tt Bedrock
Physical Address,City,and Zip
Gaston 3592779998 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: JJ icm:at;Ln Pr�c•�'
f well field,one lat/lon sufficient J
C g�is ) 22.Certification:
529360.E N 1399634 Easting w Jon Keifer Date:2021..03.21y1Jon 8:38:41f-04'00' 3/31/2021
6.Is(are)the well(s): ClPermanent 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 of this 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: 80 (ro 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• 6 (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 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