GW1-2021-07180_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lewis Lefever 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2480 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wens OR LUVER if a licable
FROM TO D1.4,ETER THICKNESS MATERIAL
Parratt-Wolff, Inc. it. ft. in,
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM I TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 fr• 58 ft- 2 in SCh40 PVC
List all applicable well permits(i.e.CounlY Slate,Variance.Injection,etc.) in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 58 ft. 68 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single) f. ft. in•!
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 54 ft- Portland Cem Tremie
Non-Water Supply Well:
EMonitoring ❑Recovery 54 ft. 56 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licible
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
56 It- 70 ft #2 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock type.gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 70 ft- 112 ft. Baekfilled with Bentonite Chips
4.Date Well 6-14-20 ABLF-PZ-01 ft. ft.
Completed: Well ID# fr. ft. ISO
5a.Well Location: ft. ft.
Duke Energy Allen Station
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
253 Plant Allen Road, Belmont 28012 riot
it. ft. ptQte�
Physical Address,City,and Zip 21.REMARKS Set,
Gaston 4 Bollar s
County Parcel Identification No.(PIN) 4"Pro Cover
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one Iat/long is sufficient)
4188021.00 N 9017969.00 w
ngn ture ofCertitied Well IntractAr Date
6.Is(are)the well(s): OPermanent or ❑Temporary 13v.signing dti.r/brm, l herebY certify that the well(s)was(were)constructed in accordance
wlth 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy of This record has been provided to the well owner.
ll'thi.s is a repair,till out known nrell construction information and explain the nature of the
repair under=21 remarkv section or on the back of this jornt 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply ire/ls ONLY with the same construction,You can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 68 24a. For All Wells: Submit this form within 30 days of completion of well
F'or multiple we11s list all depths iil differem(example-3 a 200'and 2 ct 100') construction t0 the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Iniection Wells ONLY in addition to sending the form to the address in
10 5/8 HSA 2" Spoons 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield Method of test: 24c.For Water Supply&Injection Wells:
(gPm) Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Wateo'Resources Revised August 2013