GW1-2022-01368_Well Construction - GW1_20220124

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 2581
ft. ft.
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NC Well Contractor Certification Number 15.OUTER CASING for multi-casediwells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.) 0.0 ft. .63.0 R• 1.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 63.0 fr. 73.0 ft' 1.0 'a• .010 SCH 40 PVC
❑Geothermal(Heat ing/Cool i ng Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wel Is> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 54.0 ft' PORTLANDBENTONITE SLURRY
[EMonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 60.0 ft- 73.0 rt. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/crock e, rain size,etc.
0.0 ft- 16.0 ft. BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 11/23/21 Well ID# FGDLFPZ-16 16.0 ft. 36.0 rt. BROWN SILTY SAND
5a.Well Location: 36.0 rt' 40.0 ft. DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION 40.0 rt• 73.0 ft. PWR
'-JFacility/Owner Name Facility ID#(if applicable) ft. ft. <
3195 PINE HALL ROAD BELEWS CREEK 27009 rr. ft.
n�
Physical Address,City,and Zip '"
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 54;0 60.0 FEET
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one[at/long is sufficient) 22.Certification:
36o 27' 45.02" N 80o 05' 45.57" W (>.;,,, -
12/10/21
6.Is(are)the well(s): 119Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,l hereby certify that the well(s)was(it-ere)constructer/in accordance frith
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.t1200 Well Construction Standards and that a copy
//'this is a repair,fill out known well construction igiorntation and explain the nature of the of this record has been provided to the we//owner.
repair under;'21 remarks section or on the back of this farm.
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-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: 73.0 (ft.)
for multiple wells list all depths ifdifferent(example-3@200'and 2 rt/00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 65.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f hater level is above casing,use"+"
IL Borehole diameter: 6.0 (in.) 24b. For Injection Wells:Copy to!DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR
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
Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: !
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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