GW1-2021-00883_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 DESCRIPTION
ft.NCWC 4097-A ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM TO DLAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
WI0300435 16.INNER CASING ORTUBING(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• 49 n- 6 to Schd 80 PVC
3.Well Use(check well use): ft. ft. is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 49 ` 74 ft' 6" tn• .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 49 fr. in
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT M ETHOD&AMOUNT
Non-Water Supply Well: 0 ft• 43 fr Neat Grout Tremie 150 Gallons
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. fr.
❑Aquifer Recharge InGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 43 ft• 45 ft- #1 Choker Sand JTremie
❑Experimental Technology ❑Subsidence Control 45 ft' 75 ft- #2 Filter Sand ITremie
[]Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock tym grMn size,etc.
0 ft 20 n- Not logged-Vacuum Utility Clearance
4.Date Well(s)Completed: 03/31/21 sell ID#S I W-12 20 ft- 50 ft- No Recovery
5a.Well Location: 50 ft' 60 ft- Clay
Allen Steam/Duke Energy N/A 60 ft 76 ft Sand
Facility/Owner Name Facility ID#(if applicable) 76 ff 80 ff Bedrock ..
253 Plant Allen Road, Belmont, NC 28012 ft. ft.
Physical Address,City,and Zip
ft. Ift. x tit
Gaston 3592779998 21.REMARKS t^ n
County Parcel Identification No.(PIN) t1C+1 t'pig (�QB
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: V
(if well field,one lat/long is sufficient) 22.Certification:
529188.9 N 1400208 Easting W Jon Keifer Jon 11,
2021-03-3115:57:01 3/31/2021
6.Is(are)the well(s): (nPermanent 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 (!lNo 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 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).Yowmay also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 76 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 tt 00'and 2@I00)
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 Injection Wells:Copy to DWR,Underground Injection Control(fUQ
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 27699-16 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
i
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018

ll IM 10 LA MONS NNELL
ENGINEERING
April 19, 2021
Division of Water Resources (DWR),
Information Processing Unit
1617 Mail Service Center
Raleigh,NC 27699-1636
WELL CONSTRUCTION RECORDS FOR RECOVERY WELL PERMIT
WR0300115 and UIC PERMIT TYPE OTHER WI0300435
Attached are the completed GW-1 Forms for the Allen Steam Station in Belmont,North
Carolina. Forty-four(44)total wells were installed between August 27,2020 and March 31,
2021,twenty-seven (27) extraction and nineteen (19) injection wells were installed. GW-1 Forms
for the nineteen injection wells were also submitted to the UIC Program under separate cover
(Well ID on page 2).
Extraction Well ID
EX-1 EX-16
EX-2 EX-18
EX-3 EX-19
EX-4 EX-20
EX-5 EX-21
EX-9 EX-36
EX-10 EX-42
EX-II EX-55
EX-12 EX-67
EX-13 EX-70
EX-14 EX-75
EX-15 EX-76
EX-83 EX-87
EX-84
' 6004 Ponders Court,Greenville,SC 29615 t864.268.1265 e864.288.4430 [e-mail]
BLECORP.COM

Infection Well ID
SIW-1 IW-24
SIW-2 IW-36
SIW-3 IW-42
SIW-4 IW-43
SIW-5 IW-45
SIW-6 IW-47
SIW-7 IW-73
SIW-8
SIW-9
SIW-10
SIW-I I
SIW-12