GW1-2022-01384_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
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 2581
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mull-cased wills OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
fr. ft. I 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.UIC,County,State,Variance,etc.) 0.0 ft- 51.0 ft- 1.0 in. SCH 40 PVC
3.Well Use(check well use): tr. ft. in.
17.SC
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 51.0 ft' 61.0 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 ft- 42.0 ft' PORTLANDBENTONITE SLURRY
INMonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 48.0 ft• 68.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. I 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/nicke, rain sin,etc.
0.0 tt• 10.0 ft. BROWN SILTY SANDY CLAY
4.Date Well(s)Competed: 11/29/21 well ID# FGDLFPZ-3 10.0 tt• 16.0 ft' BROWN SILTY SAND
Sa.Well Location:
16.0 fL 30.0 ft' DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION 30.0 rt• 68.0 ft• PWR
Facility/Owner Name Facility ID#(ifapplicable) ft• ft'
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address,City,and Zip ft. ft. ,)
n
STOKES 21.REMARKS "
County Parcel Identification No.(PIN) BENTONITE SEAL-42.0-48.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
360 27' 52.95" N 800 05' 40.34" W 3 -- 12/10/21
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify 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
1f 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 1121 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 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: 61.0
For rnuluple we//s list all depths ifdiJferew(example-3 r@i 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
53.0 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
//'water level is above casing,use'.+" I
11.Borehole diameter•' 6.0 (in.) 24b. For Iniection 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 Ldop 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 ver 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) Method of test:
i
13b.Disinfection type: Amount:
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources l Revised 6-6-2018