GW1-2022-01377_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 t
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 2581
n. n.
NC Well Contractor Certification Number 15.OUTER CASING for molt*-cased'wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. 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.U1C,County,State,Variance,etc) 0.0 ft' 81.0 ft. 1.0 - "' 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 81.0 ft. 91.0 ft. 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
❑Irri atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 74.0 ft. PORTLANDBENTONITE SLURRY
(EMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 80.0 ft• 93.0 ft. 20-46 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/mck type,gmin size,etc.
0.0 ft• 17.0 R• BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 11/23/21 well ID# FGDLFPZ-9 17.0 a• 39.0 e• BROWN SILTY SAND
Sa.Well Location:
39.0 fr• 45.0 ft' DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION 45.0 fr• 93.0 ft• PWR
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. a.
Physical Address,City,and Zip ft. ft. k
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-74.0-80. -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latflong is sufficient) 22.Certification:
360 27' 45.20" N 800 05' 35.02" W !:2/sr%F_ Gvy -
12/10/21
6.ls(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this fornq 1 hereby certtfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONO 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction ullbrnmtion and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks 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 pagei 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 necessan'.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 91.0 (ft.)
For multiple wells list all depths ifdifferem(example-3 tt 00'and 1@100') Submit this GW-I within 30 days Of well completion per the following:
83.5 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Il\rater level is above casing,use"+'•
11.Borehole diameter: 6.0 (in.) 24b. For Injection Wells:Copy toIDWR,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 roducin over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 161 1 MSC,Raleigh,NC 27699-I611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
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Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018