GW1-2021-00892_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-cased wells OR LINER if a Gcable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM TO DIAMETER Txlc►avFss MATERIAL
ft. ft. in.
Company Name
/p 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#' V VR03001 15 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State, Variance,etc) 0 ft. 118 ft. 6" 1m SChd 80 PVC
3.Well Use(check well use): ft. ft ra
SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 118 ft' 128 ft. 6" in .010 SChd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft• 118 ft. 'n'
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f` 114 ft- Neat Grout Tremie 150 Gallons
❑Monitoring InRecovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 116 f`• 130 1 #2 Filter Sand JTremie
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothemtal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)"
FROM TO DESCRIPTION color,hardness,soilfrock rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 20 ft. Not logged-Vacuum Utility Clearance(0'-10'),No Recovery(10'-20')
4.Date Well(s)Completed: 03/31/21 Well ID# EX-21 20 ft- 100 IL Silt
5a.Well Location: 100 f` 120 f`' Weather Rock
Allen Steam/Duke Energy N/A 120 f` 131 f` Bedrock
Facility/Owner Name Facility ID ft. ft.
#(ifapplicable)
253 Plant Allen Road, Belmont, NC 28012
Physical Address,City,and Zip ft. tI. APR X
Gaston 3592779998 21.REMARKS
1" .
County Parcel Identification No.(PIN) ^ ,ation rQu-SSI1'1
p%ti'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fat/long is sufficient) 22.Certification:
528572.1 N 1399589 Easting W Jon Keifer Jon2021-Iffer
03-3116:03:54 3/31/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form 1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IlNo 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 mvner.
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 I 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: 131 00 Submit this GW-1 within 30 days of well completion per the following:
For multiple ivells list all depths tf different(example-3 a 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
Ifwater 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: Rota'y 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:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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