GW1-2021-00921_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 I DESCRIPTION
ft. ft.
NCWC 4097-A
ft. ft. k
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a licable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM To DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
WI0300435 16.INNERCASINGORTUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) 0 ft. 34 ft.
6" ` 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 34 ft. 69 ft- 6" in- .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 34 ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT -
❑Irrl ation ❑Wells>100000 GPD FROM I TO MATERIAL EMPLACEMENT MErHOD&AMOUNT
Non-Water Supply Well: 0 ft. 28 ft. Neat Grout Tremie 150 Gallons
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge I'Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 28 it' 32 It #1 Choker Sand JTremie
❑Experimental Technology ❑Subsidence Control 32 ft. 70 It• #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,;Wit/rock type,grain size,etc.
0 It• 10 It• Not logged-Vacuum Utility Clearance
4.Date Well(s)Completed: 03/3/21 Well ID#S I W-� 10 ft. 30 ft. Clay
5a.Well Location: 30 IL 60 It. Slit
Allen Steam/Duke Energy N/A 60 It• 82.5 It• No Recovery
Facility/Owner Name Facility ID#(ifapplicable) 82.5 II' 87 ff• Weathered Rock
253 Plant Allen Road, Belmont, NC 28012 87 ft- 91 . IL Bedrock
Physical Address,City,and Zip ft. ft.
Gaston 3592779998 21.REMARKS
slit
County Parcel Identification No.(PIN) rs+�'S1Y1h
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: v
(if well field,one lat/Iong is sufficient) 22.Certification:
529316.5 N 1399458 Easting w Jon Keifer Jon 202 11--0 3-31 1 5:58:17 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 IIN0 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: 91 (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 200'and 2@I00)
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 Igiection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method: Rotary
Program,1636 MSC,Raleigh,NC 27699-1636
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
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018