GW1-2022-01404_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
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OIL
if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER' THICKNESS MATERIAL
tr. ft. � in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
Lis!all applicable hell construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft- 35.0 ft- 2.0 "' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
PPy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35.0 It. 45.0 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
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fr• 26.0 It. AQUA GUARD SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa 'licatile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 31.0 ft- 45.0 fr. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock e, lain size,etc.
0.0 ft- 9.0 ft. BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 10/04/21 Well ID# GWA-10SA 9.0 fr. 28.0 ft. BROWN SILTY SAND
5a.Well Location:
28.0 ft- 45.0 fr. DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 a. ft.
Physical Address,City,and Zip ft. ft.
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-26:0-31.0 FEET
***U-PACK SCREEN***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
360 29' 48.74" N 800 08' 21.51" W es% '"- 11/22/21
6.Is(are)the well(s)• OPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,/hereby certify that the well(s)was(here)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
ff this is a repair,fill out known well construction informalion and explain the nature of the of this record has been provided to the we0 owner.
repair under 421 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: 45.0
Submit this GW-1 within 30 daysf well completion per the following:
/%or multiple wells list all depths/fdi/jeren!(example-3@200'and 2@100') �'o
30.0 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
IJlvaler level is above casing,use"+"
11.Borehole diameter. 8.0 (in.) 24b. For Iniection Wells:Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER 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-I611
13a,Yield(gpm) Method of test:
{
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources w Revised 6-6-2018