GW1-2022-01378_Well Construction - GW1_20220124

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
rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
fr. ft, in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc) 0.0 fL 78.5 ft. 1.0 1` SCH 40 PVC
3.Well Use(check well use): rt. ft, in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 78.5 It- 88.5 f' 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 ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 70.0 ft' PORTLANDaENTONLTE SLURRY
I9Monitoring ❑Recovery R. ft.
Injection Well:
tr. 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 76.0 ft. 93.0 ft. 20-46 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,soit/mck type,grain size,etc.
0.0 ft. 17.0 ft. BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 11/23/21 Well ID# FGDLFPZ-8 17.0 rr. 39.0 fr. BROWN SILTY SAND
5a.Well Location: 39.0 ft• 45.0 fr• DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION 45.0 ft• 93.0 ft• PWR
Facility/Owner Name Facility ID4(if applicable) ft. ft.
e. rt.
3195 PINE HALL ROAD BELEWS CREEK 27009
ih r
Physical Address,City,and Zip ft. ft. a
STOKES 21.REMARKS JAN �^
County Parcel Identification No.(PIN) BENTONITE SEAL-70.0-76.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
3
(if well field,one ladlong is sufficient) 22.Certification: '
360 27' 47.76" N 800 05' 32.01" W � -
12/10/21
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this fornt,I hereby certify that the well(s)was(were)constructed in occordmtce with
7.Is this a repair to an existing well: ❑Yes or I9No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ijthi.s 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 P21 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-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: 88.5
For multiple wells list all depihs iI diJJereni(example-3 a 200'and 2 ct/00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 83•0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lJ 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 1
24c.For Water Supply and O en-Loo Geothermal Return Wells:Copy to the
a t
(i.e.auger,rotary,cable,direct push,etc.) county environmental heh department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over I00,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
r
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018