GW1-2022-01406_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 B
Well Contractor Name FROM TO DESCRIPTION
A - 2581
rt. rr. i
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if
licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0.0 ft• 69.0 It- 1 6.0 1 "" I SCH 40 PVC
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. 139.0 ft- 2.0 '"' SCH 40 PVC
3.Well Use(check well use): rt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 139.0 ft' 149.0 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 atlon ❑Wells> 100,000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 117.0 ft AQUA GUARD SLURRY
TIMonitoring ❑Recovery 00 ft. 690 ft' PORTIANDBENTONITE SLURRY
Injection Well: rt. 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 133.5 ft- 149.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control R. 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/mck type,grain size,etc.
0.0 ft• 12.0 ft• BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 10/04/21 Well ID# GWA-1 BRA 12.0 ft• 28.0 ft. BROWN SILTY SAND
5a.Well Location: 28.0 ft. 53.0 It- DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION 53.0 ft• 60.0 ft- PWR
Facility/Owner Name Facility ID#(ifapplicable) 60.0 ft- 149.0 ft' L•RbCK! `j !'. �
3195 PINE HALL ROAD BELEWS CREEK 27009 a. f.
Physical Address,City,and Zip ft. ft. ZGL?
STOKES 21.REMARKS
County Parcel Identification No.(PIN)
BENTONIfE SEAL- 117.0-133.5'FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***U-P ACK SCREEN*** '
(ifwell field,one fattlong is sufficient) 22.Certification:
360 29' 90.07" N 800 07' 83.20" W `� n.i, �j kr---
11/22/21
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the mell(s)tras(were)constructed in accordance irith
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
/f this is a repair,fill out known Krell construction information and explain the nature of the ofthis record has been provided to the urell owner.
repair under M 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 I 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: 149.0 (ft.)
/ror multiple wells list al/depths ifdifjerent(example-3 a 00'and 2 r(�r l00') Submit this GW-1 within 30 days'of well completion per the following:
10.Static water level below top of casing: 125.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
I/grater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
6.0/10.0 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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
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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,Raleigl4,NC 27699-1611
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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
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