GW1-2021-07179_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells '.
I.Well Contractor Information:
Lewis Lefever 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2480
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS DATERIAL
Parratt-Wolff, Inc. % I ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-log
FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 35 It. 2 '" SCh40 pvc
List all applicable,roll pernat.s(i.e.CounlY.State. Variance,h jec•tion,etc'.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35 ft. 45 ft. 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fc in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irrigation 0 ft' 28 fe- Portland Cem Tremie
Non-Water Supply Well:
�
28 ft- 33 ft Bentonite Chi Tremie
O Monitoring ❑Recoven
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
fr• e•
❑Aquifer Test ❑Stormwater Drainage 33 45 #2'Sand Tremie46
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soilhnck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 45 ft. 90.8 ft. Backfilled with Bentonite Chips
ft. ft.
4.Date Well(s)Completed: 5-19-21 Well ID# LB-PZ-03
ft. ft.
5a.Well Location: ft. ft.
Duke Energy Allen Station ft. ft. 2`
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
253 Plant Allen Road, Belmont 28012 ft ft pM e •
Physical Address,City,and Zip 21.REMARKS ion
Gaston 4 Bollards W.
County Parcel Identification No.(PIN) 4"Pfo Cover
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one ha/long is sufficient)
35.177618 N -81.015029 W
i nature of Certified Well .ontractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By.signing lhis Jorm, 1 herebv certift that the ue//(s)u'as(were)constructed in accordance
hrah 15A NC'AC 02C.0100 or 15A NCAC 02C.11200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EJNo copv olthis record has been provided to the well owner.
If this is a repair,Jill out known well construction in1brinatlon and explain the naure ol'the
repair under.-'21 remarks section or on the back gjthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
hor muhiple injection or non-it•ater.supply wells ONLYwith the same construction,you can
submit one,jorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 90•8 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor tnnthiple nrel/.s list all depths j dt/ferent(example-3 200'and 2 a 100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
1/hrater level is above covahg,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
10 5/8 HSA ; 2" Spoons 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
I
Form GW-I North Carolina Department of Environnhent and Natural Resources-Division of Water Resources Revised August 2013