GW1-2021-00915_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 ft. ft.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. in.
Company Name
W10300435 16.INNER CASING ORTUBING(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. 48 ft' 6" to Schd 80 PVC.
3.Well Use(check well use): ft. ft. im
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agiculttual ❑Municipal/Public 48 ft. 58 ft. 6" 1O .010 Schd 80 SS 304
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 48 ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 41 ft. Neat Grout Tremie 150 Gallons
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ItGroundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 41 " 45 ft. #1 Choker Sand Tremie
❑Experimental Technology ❑Subsidence Control 45 ft• 59 ft. #2 Filter Sand Tremie
❑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,soiVrock type,grain size,etc.
03/31/21 SIW-4 0 ft. 10 ft. Not logged-Vacuum Utility Clearance
4.Date Well(s)Completed: Well ID# 10 ft' 20 ft. No Recovery
5a.Well Location: 20 f" 40 ft. Clay
Allen Steam/Duke Energy N/A 40 ft• 50 ft• Silt
Facility/Owner Name Facility ID#(if applicable) 50 ft' 62 It. Weathered Rock s�
253 Plant Allen Road, Belmont, NC 28012 62 ft• 65.5 ft. Bedrock 2
Physical Address,City,and Zip ft. ft. 011
Gaston 3592779998 21
County Parcel Identification No.(PIN) 11 t�I �,�uR Jfir
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
529424.5 N 1399798 Easting W Jon Keifer Jon 11r
2021-03-3116:00:14 3/31/2021
6.Is(are)the well(s): CJPermanent 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 ofthe 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 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: GC 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 65.5 (ft)
For multiple wells list all depths if different(example-3@200'and 2@I00') Submit this GW-1 within 30 days of well completion per the following:
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 (iD.) 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 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
j
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources, Revised 6-6-2018