GW1-2021-03248_Well Construction - GW1_20210628

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS WATER ZONES _[ d
Well Contractor Name
f FROM TO DESCRIPTION I
A - 2581j ��E
1 ft. rt. I
NC Well Contractor Certification Number O� S 15.OUTER CASING' for multi-cased wells ORILINER if a licable.
GEOLOGIC EXPLORATION �1x Uf11Z FROM TO DIAMETER THICKNESS MATERIAL
,� tt. ft. in.
Company Name ?JOG
t a+,QnQtl 16;INNER`CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: \O�� f1�I�� FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.01C,Count, tale,Variance,etc.) 0.0 fL 21.0 ft- 2.0 } 1° SCH 40 PVC
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER'. SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 21.0 ft. 26.0 ,ft. 2.0 in.' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. . in•1
❑Industrial/Commercial ❑Residential Water Supply(shared) 18IGROUT• I 1 I
❑Uri ation ❑Wells>100,000 GPD FROM TO MATERIAL I (EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 f` 14.0 ft' PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
_ 19:`$AND/GRAVELPACIC if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 17.0 ft. 26.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additionki sheets if necessary)
FROM TO DESCRIPTION coW,hardness,soillrock e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 0 ft. 10.0 ft I RED SILTY CLAY/BOULDERS
4.Date Well(s)Completed: O5/21/21 Well ID# CCR-7RD 10.0 It. 18.0 ft. TAN SILTY SAND
Sa.Well Location:
18.0 rt. 26.0 ft' I PWR
DAN RIVER STEAM PLANT ft. ft. j
Facility/Owner Name Facility►D#(if applicable) ft. ft.
524 SOUTH EDGEWOOD ROAD EDEN 27288 ft. ft.
Physical Address,City,and Zip ft. ft.
ROCKING HAM 21.REMARKS-
County Parcel Identification No.(PIN) BENTONITE SEAL- 14.0-17.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certification:
360 29' 29.55" N 790 43' 11.04" W ow,
� 06/09/21
6.Is(are)the well(s): O Signature of Certified Well Contractor
Permanent or ❑Temporary � i Date
By signing this form,/hereby certify that he�svell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 026.0200 Weill Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner,
repair under 921 remarks section or on the back of this form.
23.Site diagram or additional well detail:
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: 26.0 (ft.)
For multiple wells list all depths ifdiifferent(example-3 rci 200'and 2 a 100') Submit this GW-1 within 30 days�of well completion per the following:
23.5 24a. For All Wells: Original form 1 to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f water level is above casing,use"+"
11.Borehole diameter: 8•0 (in.) 24b.For Injection Wells:Copy t i DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 217699-1636
12.Well construction method: AUGER 24c.For Water Supply and OpenlLoop 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
i
13b.Disinfection type: Amount:
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018