GW1-2022-01402_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Brian Thomas 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft ft
A-2581 ft. ft i
NC Well Contractor Certification Number
15.OUTER CASING for multi cased wells OR LINER if a licable
Geologic Exploration, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft 64.0 ft 6.0 in Sch 40 JPVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft T7.0 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 ❑Municipab?ublic ft 87.0 ft 2 in. .010 Sch 40 JPVC
❑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 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft 64.0 ft Portland 9entonite Slurry
[IMonitoring ❑Recovery 0.0 ft 58.0 ft Aquaguard Slurry
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 74.0 ft 89.0 ft. 20-40 IFine 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 sodfrock type in size,etc.
0.0 ft 8.0 ft Brown Sandy Silty Clay
4.Date Well(s)Completed: 12/1/21 well>D# GWA-20BRA 8 0 fL 27.0 ft Brown Silty Sand
5a.Well Location: 27.0 ft 34.0 ft Dark Brown Silty Sand
Belews Creek Steam Station 34.0 ft 51.0 ft Partially Weath6rgd_R6ck` I', '
Facility/Owner Name Facility ID#(if applicable) 51.0 ft 89.0 ft Rock. l
3195 Pine Hall Road Belews Creek 27009 ft ft 2-
Physical Address,City,and Zip ft ft
Stokes 21.REMARKS
County Parcel Identification No.(PIN) Bentonite Seal from 58.0 to 74.0 feet
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***U-Pack Screen***
(if well field,one Iattlong is sufficient) 22.Certification:
36 29' 64.74" N 80 07' 99.59" W rt57, _ 12/1/2021
6.Is(are)the well(s): InPermanent 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 MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If 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-I 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: 87.0 (ft.)
For multiple wells list all depths if different(example-3@200'and 2@100� Submit this GW-1 within 30 days of well completion per the following:
85.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617iMSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
11.Borehole diameter: 6.0 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary 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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018