GW1-2021-00922_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
ft. ft.
NCWC 4097-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Gcable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM To DIAM ErER THICKNESS 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 ft. 72 ft- 61
1
rn Schd 80 JPVC
3.Well Use(check well use): fr. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMEPEW SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 72 ft- 82 ft. 6" i L .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 72 ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01ni ation ❑Wells>100000 GPD FROM I TO MATERIAL EMPLACEMENT M EPHOD&AMOUNT
Non-Water Supply Well: 0 ft- 65 ft• Neat Grout Tremie 150 Gallons
❑Monitoring ❑Recovery fr. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge InGroundwater Remediation
19.SAND/GRAVEL PACK if a licable i
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMEIMOD
❑Aquifer Test ❑Stormwater Drainage 65 ft- 69 ft- #1 Choker Sand Tremie
❑Experimental Technology ❑Subsidence Control 69 ft- 82 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,soiUmck type,grain size,etc.
0 fr 20 ft Not logged-Vacuum Utility Clearance(0'-10'),Clay(1W-20')
4.Date Well(s)Completed: 03/31/21 Well ID# SIW-1 0 20 fr 82.5 fr' Sift
5a.Well Location: 82.5 fr 87 ft• Weathered Rock �-
Allen Steam/Duke Energy N/A 87 ft- 91 ft. Bedrock
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
253 Plant Allen Road, Belmont, NC 28012 fr. ft. x
Physical Address,City,and Zip
Gaston 3592779998 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
529316.5 N 1399458 Easting w Jon Keifer Jon 20211<-03-3115:57:54 3/31/2021
6.Is(are)the well(s): nPermanent or ❑Temporary Signature of Certified Well Contractor Date
by signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15ANCAC 02C.0100 or l5A 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 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 27699-16 17
If water level is above casing,use"+
II.Borehole diameter: 10 (in.) 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-Coop 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
f
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018