GW1-2021-00911_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
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a lieable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM TO DIAMETER THIclavEss MATERIAL
ft. ft. in.
Company Name
WI0300435 16.INNER CASING ORTUBnvG eothermalclosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 0 ft. 58 ft. 61
1
rn Schd 80 PVC
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 58 fr. 83 ft. 6" to .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 58 fr, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fr• 34 fr• Neat Grout Tremie 150 Gallons
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge [nGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 34 ft. 36 ft. #1 Choker Sand ITremie
❑Experimental Technology ❑Subsidence Control 36 ft. 84 ft. #2 Filter Sand JTremie
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0 ft• 15 ft• Not logged-Vacuum Utility Clearance
4.Date Well(s)Completed: 03/31/21 Well ID# I W-73 15 e• 40 ft• Sift
5a.Well Location: 30 f" 80 ft- Sand
Allen Steam/Duke Energy N/A 75 ft• 84 ft• Bedrock
Facility/Owner Name Facility ID#(ifapplicable)
253 Plant Allen Road, Belmont, NC 28012 fr. ft.
Physical Address,City,and Zip
ft. ft.
Gaston 3592779998 21.REMARKS c Nit
County Parcel Identification No.(PIN)
iit1�I1;:3110, t'c Ct10D
r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification'
529059.2 N 1400192 Easting W Jon Keifer Jon Keifer 5:09:39 3/31/2021
6.Is(are)the well(s): OPermanent 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 InNo I5ANCAC 02C.0100 or I5A 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#2I 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: 84 (ft) 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@I00)
24a. For All Wells: Original form W to Division of Water Resources (DR),
f 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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018