GW1-2021-00919_Well Construction - GW1_20210402

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Y
Jon Keifer 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
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. FROM TO mAMEI•ER TxICIavEss MATERIAL
ft. ft. in.
Company Name
WI0300435 16.INNER CASING ORTUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 0 ft' 30.5 f`' 6" "' Schd 80 JPVC
3.Well Use(check well use): ft. I ft. I in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30.5 ft- 60.5 f`• 6" in. .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft- 30.5
❑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• 20.5 f`• Neat Grout Tremie 150 Gallons
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge CJGroundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 20.5 f` 24.5 f` #1 Choker Sand ITremie
❑Experimental Technology ❑Subsidence Control 24.5 f` 62.5 k' #2 Filter Sand JTremie
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach addilionil sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
0 f` 10 f`- Not logged-Bentonite
4.Date Well(s)Completed: 03/31/21 well ID# S 1 W-7 10 f`• 40 ft- Sand
5a.Well Location: 40 ft' 50 f`• Clay
Allen Steam/Duke Energy N/A 50 f`• 73.5 n- Weathered Rock
Facility/Owner Name Facility ID#(if applicable) 73.5 ft• 77 n- Bedrock
253 Plant Allen Road, Belmont, NC 28012 k. ft. `
Physical Address,City,and Zip
ft. ft.
Gaston 3592779998 21.REMARKS
County Parcel Identification No.(PIN)
U pit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatilong is sufficient) 22.Certification:
529350.9 N 1399576 Easting w Jon Keifer Jon 20211--03-3115:58:57 3/31/2021
6.Is(arc)the well(s): InPermanent 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 02CI.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#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: 77 (ft) 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: (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)
o Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rita'1�/ 24c.For Water Supply and Open-lo op 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 276 99-16 1 1
13a.Yield(gpm) Method of test: ,
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018