GW1-2022-01380_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
R. ft.
A - 2581
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for muT-cased welts OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
fr. tr. I in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.WCII CODStrUCtlOn Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UC,County,State,Variance,etc) 0.0 ft- 43.0 ft. 1.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM
SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 43.0 ft' 53.0 ft' 1.0 "' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 l" 35.0 ft- PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery fr. 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 41.0 ft. 53.0 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,gmin size,etc.
0.0 ft. 11.0 ft. BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 11/19/21 well ID# FGDLFPZ-24 11.0 ft. 28 0 tL BROWN SILTY SAND
5a.Well Location: 28.0 ft' 31.0 ft' DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION 31.0 rt• 53.0 ft• E pWR I, `
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. ^^
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address,City,and Zip ft. ft.
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-35:0-41.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hat/long is sufficient) 22.Certification.-
360 27' 27.10" N 800 05' 61.15" W 3 -- Ow- 12/10/21
6.Is(are)the well(s)• (EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the well(s)was(were)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 Construciion Standards and that a copy
if this is a repair,fill out known we//construction information and explain the nature of the of this record has been provided to the well owner.
repair under 4*21 renmrks 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 necessary.
drilled: 24.SUBMITTAL INSTRUCTION'S
9.Total well depth below land surface: 53.0 (ft.)
hur multiple wells list all depths i/'diJJerem(example-3@200'and 1@100') Submit this GW-1 within 30 days of well completion per the following:
47.0 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 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Penn it Program,1611 MSC,Raleigh,NC 27699-I61 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