GW1-2021-00912_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
NCWC 4097-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FRom To DIAMETER THICKNESS MATERIAL
ft. ft.
Company Name
W10300435 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 0 ft. 45 ft' 6° to Schd 80 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN [
FROM TO DIAMETER ! SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 45 ft. 80 ft- 6" 1° .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 45 ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
❑Irri ation ❑Wells>100000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 38.5 ft- Neat Grout Tremie 150 Gallons
❑Monitoring ❑Recovery 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 EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 38.5 ft. 42.5 ft. #1 Choker Sand ITremie
❑Experimental Technology ❑Subsidence Control 42.5 "' 82 ft. #2 Filter Sand ITremie
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explainunder#21 Remarks) 0 ft. 20 ft. Not logged-Vacuum Utility Clearance(0'-10'),No Recovery(10'-20')
4.Date Well(s)Completed: 03/31/21 Well ID#S I W-1 20 ft. 40 ft. Clay
59.Well Location: 40 ft. 80 ft. Sift
Allen Steam/Duke Energy N/A 80 ft. 91 ft. Weathered Rock
Facility/Owner Name Facility iD#(ifapplicable) 91 ft- 95 ft. Bedrock
253 Plant Allen Road, Belmont, NC 28012 ft. ft.
Physical Address,City,and Zip ft. I ft.
Gaston 3592779998 21.REMARKS .It
r? nrt'sa
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
529466 N 1399909 Easting w Jon Keifer Jon lifer
2021-03-3116:01:29 3/31/2021
6.Is(are)the well(s): IlPermanent 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 ONo 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 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 ito provide additional well construction info
construction,only 1 GWA 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: 95 00 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(RUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Notary
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:
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018