GW1-2021-00904_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
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a 6cable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FR°M To DIAMETER THICIavEss MATERIAL
ff. I, I in.
Company Name
WI0300435 16.INNER CASING ORTUBING eothermalclosed-lao
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 0 ff. 27 ft. 611 1O Schd 80 PVC
3.Well Use(check well use): ft. ft. is
17.SCREEN
Water Supply Well:
pp y FROM TO DIAMETER SLOT SI7E THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 27 It- 52 1' 6" in. .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 27 ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi ation ❑Wells>100000 GPD FROM I TO MATERIAL EMPLACEMENT M ETHOD&AMOUNT
Non-Water Supply Well: 0 It. 19 ft Neat Grout Tremie 150 Gallons
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ff. ft.
❑Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 19 ft' 25 ft #1 Choker Sand JTremie
❑Experimental Technology ❑Subsidence Control 25 ft. 54 ft. #2 Filter Sand JTremie
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additionil sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soillrock rain size etc.
0 It. 10 ft Not logged-Vacuum Utility Clearance
4.Date Wells)Completed: 03/31/21 well ID# 1 W-43 10 ft 13.5 ft' Not Recovery
5a.Well Location: 13.5 ff' 30 It. Silt
Allen Steam/Duke Energy N/A 30 ft 50 it- Sand
Facility/Owner Name Facility ID#(if applicable) 50 It' 159 ft- Bedrock a A�
253 Plant Allen Road, Belmont, NC 28012
Physical Address,City,and Zip ft. ft.
Gaston 3592779998 21'REMARKS .
i,rores.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification:
529597.8 N 1399970 Easting w Jon Keifer 2021-03-3115:5a:28 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 01C.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#11 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: 55 (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
If water level is above casing,use"+"
11.Borehole diameter: 10 (in,) 24b.For Iniection 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 27699-1611
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