GW1-2021-00920_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.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR L1NER if a ticable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM ro DIAMErER THICIQVFSS MATERIAL
ft. ft. in.
Company Name
WI0300435 16.INNER CASING ORTUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 0 It. 60 ft- 611 Schd 80 JPVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 60 ft. 70 ft' 6" in. .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft 60 ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100000 GPD FROM I TO MATERIAL EMPLACEMENT MErHOD&AMOUNT
Non-Water Supply Well: 0 ft. 54 ft- Neat Grout 150 Gallons Tremie
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge 17Groundwater Remediation
19.SAND/GRAVEL PACK if a Iicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 54 It. 58 ft- #1 Choker Sand JTremie
❑Experimental Technology ❑Subsidence Control 58 ft. 74 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 TO DESCRIPTION color,hardness soiVrock type,grain size,etc.
0 It. 10 ft. Not logged-Vacuum Utility Clearance
4.Date Well(s)Completed: 03/31/21 Well DO S I W-8 10 ft. 50 ft. Sand
5a.Well Location: 50 ft' 60 It' No Recovery
Allen Steam/Duke Energy N/A 60 It. 73.5 It• Weathered Rock
Facility/Owner Name Facility ID#(if applicable) 73.5 f' 77 It. Bedrock 2
253 Plant Allen Road, Belmont, NC 28012
Physical Address,City,and Zip
Gaston 3592779998 21.REMARKS W
County Parcel Identification No.(PIN) 'nn t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: R
(if well field,one lat/long is sufficient) 22.Certification:
529350.9 N 1399576 Easting W Jon Keifer
Jon Keifer 2021-03-3115:58:37 3/31/2021
6.Is(are)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 IlNo 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#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@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
If water level is above casing,use"+"
II.Borehole diameter: 10 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(NC)
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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018