GW1-2022-01396_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
Well Contractor Name FROM TO DESCRIPTION
A - 2581 ft. ft.
ft. fr.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER' THICKNESS MATERIAL
tr. tr. I in.
Company Name 1
16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#• FROM TO I DIAMETER I THICKNESS I MATERIAL
1,ist all applicable well construction permits(i.e.UIC,County.Stale.Variance,etc) 0.0 ft- 39.0 ft- 2.0 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 39.0 ft' 49.0 ft. 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl atlon ❑Wells>100000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 31.0 ft- AQUA GUARD SLURRY
OMonitoring ❑Recovery R. ft.
Injection Well: ft. it.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/G RAVEL PAC K ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 35.0 ft- 49.0 rt' 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,soil/rock type,grain sine,etc.
0.0 ft- 12.0 ft- BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 10/04/21 Well ID# CP-10S 12.0 rt• 33.0 tL BROWN SILTY SAND
5a.Well Location: 33.0 ft• 49.0 it' DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address,City, ft.
,and Zip 7
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-31.0-35.0 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 29' 71.48" N 800 07' 70.20" W 3n;,,, (al,.r--
11/22/21
6.Is(are)the well(s)• CEPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or INNo 15A NCAC 02C.0100 or 15A NCAC 02C'0100 Well Construction Standards and that a copy
IJ'this is a repair,Jill out known well construction information and explain the nature ofthe 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 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: 49.0 (ft.)
For multiple wets list all depths ifdierent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
33.0 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
IJ'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-Loon 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 ov`er;100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,INC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
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Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018