GW1-2022-01395_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 i
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 2581
ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft. 34.0 ft- i"6.0 SCH 40 PVC
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 ft• 45.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 45.0 It- 55.0 ft' 2.0 in-! .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.11
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrl ation ❑Wel Is>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 33.5 ft- AQUA GUARD SLURRY
OMonitoring ❑Recovery 0.0 ft. 34.0 ft' PORTLANOBENTONTTE SLURRY
Injection Well:
fr. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PAC K ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 40.0 ft. 57.0 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/rackmin size,etc.
0.0 ft 6.0 ft• BROWN SILTY SAND
4.Date Well(s)Completed: 10/04/21 Well ID# CP-96R 6.0 ft• 13.0 ft• DARK BROWN SILTY SAND
5a.Well Location: 13.0 ft• 30.0 ff PWR
BELEWS CREEK STEAM STATION 30.0 ft• 57.0 ft• ROCK
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. r
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3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address,City,and Zip ft. ft.
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-33.5-40.0 FEET -
''
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***U-PACK SCREEN"*
(if well field one lat/long is sufficient) 22.Certification:
360 28' 05.30" N 800 06' 53.46" W !:�I:sn;;- Pr--
11/22/21
6.Is(are)the well(s)• 251'ermanent 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 15No I5A NCAC 01C.0100 or ISA NCAC 01G.0100 Well Construction Standards and that a copy
If this is a repair,fil/out known well construction information and explain the nature of the of'this record has been provided to the well owner.
repair under 172/renharks 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: 55.0 (ft.)
For multiple wells list all depths ifdyferent(example-3@200'and 1 r(�t/00') Submit this GW-1 within 30 days of well completion per the following:
$•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
lj'woter level is above casing,use"+" 1
11.Borehole diameter: 6.0/10.0 (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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018
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