GW1-2021-00887_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. ft.
NCWC 4097-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a licable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM To DKAM ETER TxICKINEss MATERIAL
ft. fr. 6 I in.
Company Name
16,INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WR03001 15 FROM TO DIAMETER TRICKINESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 0 It. 180 ft. 6° In' Schd 80 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE TRICKINESS MATERIAL
❑Agricultural ❑Municipal/Public 180 ft. 190 ft. 6 'n• .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) It- 180 ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTl atlon ❑Wells>100000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It. 174 It- Neat Grout Tremie 525 Gallons
❑Monitoring InRecovery ft. ft.
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
❑Aquifer Test ❑Stormwater Drainage 178 f`• 192 ft. #2 Filter Sand Sand Inside 10"
❑Experimental Technology ❑Subsidence Control ft. fr.
❑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/rock type,grain size,etc.
0 ft. 10 ft- Not logged-Vacuum Utility Clearance
4.Date Well(s)Completed: 03/3.I 1/2 1.1 well m# EX-15 10 ft• 60 ft Clay
5a.Well Location: 37 ft. 190 f`' Sand
Allen Steam/Duke Energy N/A 190 ft- 202 ft. Bedrock
Facility/Owner Name Facility ID#(if applicable) ft. ft.
G.
253 Plant Allen Road, Belmont, NC 28012 ft. ft. v
Physical Address,City,and Zip ft. ft. APR !�
Gaston 3592779998 21.REMARKS it
County Parcel Identification No.(PIN)
icrrr.3Clon -,..
J �
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
529240.6 N 1399077 Easting w Jon Keifer !oa ea'Zo2gned byJ z Keifer o' 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 MNo 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 ofthis 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: 202 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 rd 00'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
If water level is above casing,use
11.Borehole diameter: 10.. 24b. For Iniection Wells:Copy to,DWR,Underground Injection Control(IUQ
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotosonlc
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