GW1-2022-01379_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 DESCRIPTIONft. rt- j
A - 2581 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased,wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
a. rt. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable we//construction permits(i.e.ULC,County,Slate,Variance,etc.) 0.0 ft- 74.0 ft- 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 74.0 rt• 84.0 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 ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fL 68.0 fL PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery
Injection Well:
rt. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 74.0 ft- 910 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/mck type,gimin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft- 17.0 ft• BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 11/23/21 Well ID# FGDLFPZ-7 17.0 ft• 39.0 ft BROWN SILTY SAND
5a.Well Location: 39.0 ft• 45.0 ff DARKjBRQWN SILTY=SAND 1
BELEWS CREEK STEAM STATION 45.0 ft• 91.0
Facility/Owner Name Facility I D#(if applicable) ft. ft. -
3195 PINE HALL ROAD BELEWS CREEK 27009 D. ft.
Physical Address,City,and Zip ft. ft.
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL-68.0-74.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
360 27' 46.81" N 800 05' 34.08" W 12/10/21
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing lhis form,L hereby c•erlify that the wel/(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I9No 15A NCAC 02C.0L00 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Y this 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'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 1 GW-1 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: 84'0 (ft.)
Por multiple wells list all depths ifdifferent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
79•0 24a. For All Wells: Original form to Division of Water Resources (DWR),
]0.Static water level below top of casing: (ft.)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lflvaler level is above casing,use"+"
24b. For Injection Wells:Copy toDWR,Underground Injection Control (IUC)
11.Borehole diameter: 6.0 (in,)
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:
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018