GW1-2021-03247_Well Construction - GW1_20210628

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS
14.'WATER20NES 1 ;t
Rp�° FROM TO DESCRIPTION I
Well Contractor Name BAD® ft. ft.
A - 2581 rt. rt.
.8 2021 NC Well Contractor Certification Number JUN 2 15.OUTER CASING for'multi-cased wells OR:LINER'if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
lic __. ..Pr ssi g Unit ft. ft. in.
Company Name .aI
DWR.Seclon 16.INNER CASING OR TUBING fizeothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,Slate,Variance,etc.) 0.0 ft- 34.0 ft- 2.0 ` i"' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.,SCREEN
FROM TO DIAMETER t SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 34 ft. O tt. 2.0 in.t 010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. i
❑Industrial/Commercial ❑Residential Water Supply(shared) iS GROUT
❑Litt ation ❑Wells>100,000GPD FROM I TO MA'I•ERIAL I IEMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 It- 29,0 ft' PORTLAND BENTONITE SLURRY
Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19"SAND/GRAVEL PACK lla liceble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 31.0 ft- 44.0 n 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft. I I
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ill necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 ft• 13.0 ft- RED CLAY/BOULDERS
4.Date Weil(s)Completed: 05/19/21 well ID# CCR-4RD 13.0 rt. 27.0 ft- BLACK SILTY SAND
Sa.Well Location: 27.0 ft' 45.0 ft.
PWR
DAN RIVER STEAM PLANT ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
524 SOUTH EDGEWOOD ROAD EDEN 27288 ft. ft.
Physical Address,City,and Zip ft. ft.
ROCKINGHAM 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL-29.0-31.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(if well field,one lat/long is sufficient) 22.Certification:
360 29' 29.55" N 790 43' 11.04" W , t'j1k -
f 06/09/21
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,!hereby cer[tfy that he i vell(s)was(were)constructed in accordance wish
7.Is this a repair to an existing well: ❑Yes or IJNo ISA.NCAC 02C.0/00 or 15A NCAC 02Gt.0200 We�/Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of ibis record has been provided to the we'll owner.
repair under 021 remarks section or on the back ofrhis form.
23.Site diagram or additional weil'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-I 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: 44.0 (ft.)
For multiple,vells list all depths ifdii ferenr(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 25.0 (ft) 24a' For All Wells: Original fo i to Division of Water Resources (DWR),
If roarer level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy tot DWR,Underground Injection Control (IUC)
AUGER Program,1636 MSC,Raleigh,NC 2I 699-1636
12.Well construction method: 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 producine over 100,1100 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
1
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources p Revised 6-6-20I8