GW1-2021-00923_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
NCWC 4097-A ft. ft.
ft. ft.
NC Well Contractor Certification Number I5.OUTER CASING for multi-cased wells OR LINER if a livable
Landprobe, Dept. of Bunnell Lammons Eng., Inc. FROM TO DIAMETER THICIavEss MATERIAL
ft. ft. in.
Company Name
WI0300435 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, variance,etc) 0 ft. 57 ft. 6" to Schd 80 PVC
3.Well Use(check well use): ft. ft. is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 57 ft. 87 ft' 6" tn• .010 Schd 80 SS 304
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr, 57 ft, in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT i
❑Irri ation ❑Wells>100000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 50 ft. Neat Grout Tremie 150 Gallons
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge I'Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 50 ft 54 ft #1 Choker Sand ITremie
❑Experimental Technology ❑Subsidence Control 54 ft. 88 ft. #2 Filter Sand ITremie
❑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,soil/rock type,grain size,etc.
0 ft. 20 ft. Not logged-Vacuum Utility Clearance(0'-1 0'),Clay(10'-20')
4.Date Well(s)Completed: 03/31/21 Well ID#S IW-1 1 20 ft. 60 ft Silt
5a.Well Location: 40 ft• 60 ft- Bedrock
Allen Steam/Duke Energy N/A
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
253 Plant Allen Road, Belmont, NC 28012 ft. ft.
Physical Address,City,and Zip ft. ft. rPse311�C� �,�
Gaston 3592779998 21.REMARK
County Parcel Identification No.(PIN) w J „+�e^� J 4
v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
529232.9 N 1400274 W Jon Keifer Jon liter
2021-03-3115:57:32 3/31/2021
6.Is(are)the well(s): [!]Permanent 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 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/fthis 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 92/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 I 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: 99 (fL) 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 2 7699-16 17
If water level is above casing,use"+"
11.Borehole diameter: 1 (in.) 24b. For Infection Wells:Copy to!DWR,Underground Injection Control(NC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Ro*lary 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(gP m) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018