GW1-2021-00901_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
ft, ft.
NCWC 4097-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM TO DIAMETER THICKNFss MATERIAL
ft. ft. I in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#• M03001 15 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 0 ft. 59 ft- 6" 'm Schd 80 PVC
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 59 ft. 69 1" 6 i- .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 59 g in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100000GPD FROM I TO MATERIAL EMPLACEMENT MEI'HOD&AMOUNT
Non-Water Supply Well: 0 ft 53 ft- Neat Grout Tremie 150 Gallons
❑Monitoring InRecovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRA VEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 57 tt' 69 ft #2 Filter'Sand Tremie
❑Experimental Technology ❑Subsidence Control
❑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,wil/rock type,grain size,etc.
0 k 10 tt Not logged -Vacuum Utility Clearance
4.Date Well(s)Completed: 03/31/21 Well ID# EX-83 10 it 30 tt No Recovery
5a.well Location: 30 tt' 40 tt' Silt
Allen Steam/Duke Energy N/A 40 it 62 ft- Sand
Facility/Owner Name Facility ID#(if applicable) 62 it 69 tt Bedrock r @d h
253 Plant Allen Road, Belmont, NC 28012 e. e. I
Physical Address,City,and Zip ft. ft. APR X
Gaston 3592779998 21.REMARKS
rC1�;W'FiSI
County Parcel Identification No.(PIN)
per
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
529321.9 N 1399522 Easting p 1Y8ew Jon Keifer :'Digitally
aa 202.032111834104'00 3/31/2021
6.Is(are)the well(s): [!]Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert;y that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I'JNO 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 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: 69 00 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if 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: (fk) Information Processing Unit,1617 MSC,Raleigh,NC 2 76 99-16 17
Ifwater level is above casing,use"+"
11.Borehole diameter: 6 (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 27699-16 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 6-6-2018