GW1-2021-00907_Well Construction - GW1_20210402

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
a
Jon Keifer 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name
ft. I ft.
NCWC 4097-A
ft. I ft.
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR LINER if a Ii le
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM TO DIAMETER THICIrnEss MATERIAL
ft. ft. in.
Company Name
WI0300435 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 0 ft- 63 ft- 6" rn Schd 80 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO DIAMETER SLOT SI'I.
17.SCREEN
7,E THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 63 ft. 88 It. 6" rn' .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 63 fI. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT t
❑Irrigation ❑Wells>100000 GPD FROM I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft- 57 ft- Neat Grout Tremie 150 Gallons
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge [IGroundwater Remediation
19.SAND/GRA VEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDrainage 57 ft. 61 ft- #1 Choker Sand JTremie
❑Experimental Technology ❑Subsidence Control 61 ft- 90 ft- #2 Filter Sand Tremie
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM I TO DESCRIPTION color,hardness,soil/ruck type,grain size,etc.
0 ft- 20 ft- Not logged-'Vacuum utility Clearance(0A0),No Recovery(10'-20')
4.Date Well(s)Completed: 03/31/21 Well ID# I W-36 20 ft- 40 ft' Clay
5a.Well Location: 40 ft' 60 ft. Slit
Allen Steam/Duke Energy N/A 60 ft- 80 ft- No Recovery
Facility/Owner Name Facility ID#(ifapplicable) 80 ft' 93 ft' Bedrock
253 Plant Allen Road, Belmont, NC 28012 ft. ft. .
Physical Address,City,and Zip
Gaston 3592779998 21.REMARKS '.
County Parcel Identification No.(PIN) U1111
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
rf well field,one lat/lon is sufficient Dw J
C g ) 22.Certification:
529368.E N 139932E Easting W Jon Keifer 2Jon 1,1r
021-03-3116:02:15 3/31/2021
6.Is(are)the well(s): dPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!nNo 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f 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 921 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-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: 93 (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
1f water level is above casing,use"+"
It.Borehole diameter: 10 (in.) 24b. For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Kota'7r�� 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
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018