GW1-2022-01407_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES #
Well Contractor Name FROM ft. TO ft. DESCRIPTION j�
A - 2581 ft. ft. f
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased-wells OR.LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. 'in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable we0 construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 IL 34.0 ft- 2.0 t"' 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 34.0 ft' 44.0 R. 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
❑Irrl ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 21.0 ft. AQUA GUARD SLURRY
OMonitoring ❑Recovery R. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a litable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 29.0 ft- 46.0 n- 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/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 SA 12.0 It- 28.0 rt BROWN SILTY SAND
5a.Well Location: 28.0 ft- 46.0 ff 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 ft. ft.
Physical Address,City,and Zip ft. ft. - ..
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL=21.0-29.0 FEET
5b.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' 50.07" N 800 07' 23.20" W '" 11/22/21
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,l hereby certify that,the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction information and explain the nature of the of this record has been provided to the widl 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: 44.0 (ft.)
Por multiple wells list al/depths ifdiercm(example-3@200'and 2 a l00') Submit this GW-1 within 30 days of well completion per the following:
31.0 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
/*water level is above casing,use"+"
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells:Copy to I DWR,Underground Injection Control(IUC)
12.Well construction method: AUGER
Program,1636 MSC,Raleigh,NC 27699-1636
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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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