GW1-2021-00895_Well Construction - GW1_20210402

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jon Keifer 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
fr. ft.
NCWC 4097-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FR°M TO DIAM EIER THICIrnFss MATERIAL
ft. ft. ':in.
Company Name
�p 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• V VR03001 15 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 0 ft. 65.5 ft. 6" m Schd 80 PVC
3.Well Use(check well use): 17.
Water Supply Well: FROMREE TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 65.5 rt. 75.5 ft. 6" '"' 1.010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 65.5 ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT l
❑Irri ation ❑Wells>100000 GPD FROM I TO MATERIAL EMPLACEMENT MEPHOD&AMOUNT
Non-Water Supply Well: 0 ft. 58.5 ft. Neat Grout Tremie 150 Gallons
❑Monitoring 17Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMErHOD
[]Aquifer Test ❑Stormwater Drainage 63.0 ft. 77.0 fL #2 Filter Sand Tremie
❑Experimental Technology ❑Subsidence Control ft. ft.
❑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 rain size,etc.
0 rt• 10 ft- Not logged-Vacuum Utility Clearance
4.Date Well(s)Completed: 03/3.I I/2.f 1 Well ID# EX-42 10 ft. 77 ft• Sand
5a.Well Location: 77 rt' 92 rt• Bedrock
Allen Steam/Duke Energy N/A
P,
Facility/Owner Name Facility ID#(if applicable) ft. ft. Zk
253 Plant Allen Road, Belmont, NC 28012
Physical Address,City,and Zip ft. ft. 20
Gaston 3592779998 zl'REMARKS
County Parcel Identification No.(PIN) "'r^ r'. 'L-40n Processing
rivilt
D�F4 f1 Sectioll
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
526102.7 N 1400491 Easting w Jon Keifer Digitally signed by Jon Keifer 3/31/2021
Date:2021.03.22 08:38:57-04'00'
6.Islam)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
Bysigning 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 of this 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: 92 (fL) 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@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)
12.Well construction method: Rotary Program,1636 MSC,Raleigh,NC 27699-1636
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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018