GW1-2022-01369_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft. f
A - 2581
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING Neothermal 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 ff 71.0 ft. 1.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FR SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 71.0 ft' 81.0 ft' 1.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 62.0 ft. PORTLANDBENTONITE SLURRY
(EMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 68.0 ft• 81.0 a' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑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/imck type,grain size,etc.
0.0 fL 17.0 ft- BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 11/23/21 Well ID# FGDLFPZ-15 17.0 a. 33.0 ft. BROWN SILTY SAND
5a.Well Location: 33.0 ft' 42.0 ft' DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION 42.0 ft• 81.0 e• I _PWRi
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft. J 0
Physical Address,City,and Zip ft. ft.
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-62.0-68.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
360 27' 42.88" N 800 05' 43.34" W Gw- 12/10/21
6.ls(are)the well(s): (EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this fornt,1 hereby certify that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or (ENo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction infbrntation and explain the nature of the oJ'this record has been provided to the we//owner.
repair under L21 rentarks section or on the back ofthis 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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTION'S
9.Total well depth below land surface: 81.0
For multiple wells list all depths ifdi7ferent(example-3 ct 00'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
75.0 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 27699-1617
if irater level is above casing,use
11.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-Loon 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 roducing Liver 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018