GW1-2021-00894_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
fr. ft.
NCWC 4097-A fr fr
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a" Gcable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM TO DIAMETER TH1CIavFss MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WR03001 15 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, variance,etc.) 0 fit. 54.5 ft. 6" to Schd 80 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 54.5 fit• 64.5 ft. 6 "' .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 54.5 ft- in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUTk
01iri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT M ETHOD&AMOUNT
Non-Water Supply Well: 0 fit• 47 fit• Neat Grout Tremie 150 Gallons
❑Monitoring I'Recovery
Injection Well:
ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PAC K if applicable)
'•1:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 51.5 ft. 67 ft. #2 Filter Sand Tremie
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach idditional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soill ektyM grain size,etc.
0 ft. 10 ft. Not logged -Vacuum Utility Clearance
4.Date Well(s)Completed: 03/31/21 Well ID# EX-1 10 fit• 30 ft. Clay
5a.Well Location: 30 fit 65 fit• Sand
Allen Steam/Duke Energy N/A 65 ft- 69 ft. Bedrock li
Facility/Owner Name Facility ID#(ifapplicable) 69 ft. 75 ft. No Recove 4� Yam'
253 Plant Allen Road, Belmont, NC 28012
Physical Address,City,and Zip APR XA 021
Gaston 3592779998 21.REMARKS I I Alt
County Parcel Identification No.(PIN) { nprcceSSing nl
DWR SQuron
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
529749.1 N 1400535 Easting W Jon Keifer Date:Digitally
02signed..03.211y1Jon
8:38:41fe-04'o0' 3/21/2021
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 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: 75 00 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@I001
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(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:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018