GW1-2021-00914_Well Construction - GW1_20210402

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jon Keifer 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
ft. ft.
NCWC 4097-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ticable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM TO DIAMETER THICIavEss MATERIAL
ft. ft. in.
Company Name
W10300435 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 0 ft' 35 ft' 6" rn Schd 80 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER I SLOT S17E THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 35 fr. 50 ft. 6" tn' :010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 35 ft is
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT `
❑Irri ation ❑Wells>100000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 28 ft. Neat Grout Tremie 150 Gallons
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 28 ft. 32 fl #1 Choker Sand JTremie
❑Experimental Technology ❑Subsidence Control 32 ft 151 ft- #2 Filter Sand JTremie
❑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,soil/mck type,grain size,etc.
0 ft• 10 ft• Not logged-Vacuum Utility Clearance
4.Date Well(s)Completed: 03/31/21 Well ID#SIW-3 10 ft' 20 ft. No Recovery
5a.Well Location: 20 ft. 40 ft- Clay
Allen Steam/Duke Energy N/A 40 ft• 50 ft. Silt
Facility/Owner Name Facility ID#(ifapplicable) 50 ft' 60 ft. Weathered Rock
253 Plant Allen Road, Belmont, NC 28012 60 ft• 65.5 ft- Bedrock I t
Physical Address,City,and Zip ft. ft.
Gaston 3592779998 21.REMARKS
County Parcel Identification No.(PIN) Uttll
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Irtiormation on .
(ifwell field,one Iat/long is sufficient) 22.Certification'
529424.5 N 1399798 Easting W Jon Keifer 2on Keifer
021-03-3116:00:37 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 ItNo 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: 65.5 (ft)
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
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
lfwater level is above casing,use"+"
11.Borehole diameter: 10 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
12.Well construction method: Rotary
Program,1636 MSC,Raleigh,NC 27699-1636
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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018