GW1-2022-01375_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4121
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if tt licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) 0.0 ft. 54.0 ft. 1.0 in. SCH 40 PVC
3.Well Use(check well use): R. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 54.0 ff 64.0 fL 1.0 in.! .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑WeIIs>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 46.0 ft' PORTLANDBENTONITE SLURRY
&Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 52.0 ft. 68.0 ft- 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/mck type,gimin size,etc.
0.0 a• 13.0 ft• BROWN SILTY SANDY CLAY
4.Date WcII(S)Completed: 11/23/21 Well ID# FGDLFPZ-11 13.0 a• 33.0 ft• BROWN SILTY SAND
5a.Well Location: 33.0 ft' 38.0 ft- DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION 38.0 ft. 68.0 ft. PWR ; [, -�`' f 11.1-
Facility/Owner Name Facility ID#(if applicable) ft. ft. '',
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft. l
Physical Address,City,and Zip ft. ft.
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-46:0­52:0 FEET-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lit/long is sufficient) 22.Certification: %�� " ,�//i�
360 27' 45.35" N 800 05' 46.55" W '! !x s/1�`1',i, 12/10/21
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this.form,1 hereby certify that the we/l(s)was(mere)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/fthi.s is a repair,Jill out known well construction infornration and explain the nature ofthe ofihis record has been provided io the well owner.
repair under#21 remarks section or on the back of this 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 Over'in Remarks Box).You may also attach additional pages if necessap'.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 64.0 (ft.)
For multiple wells list all depths ifdifJerent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
59.0 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
1l'water 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-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources k Revised 6-6-2018
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