GW1-2022-01410_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 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for molt'-cased!wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name
16.INNER CASING OR TUBING eothermal 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. 48.0 ff 1.0 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 48.0 ft' 58.0 ft' 1.0 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 I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 40.0 ft. PORTLANDBENTONITE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 46.0 It- 58.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control rt. 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 size,etc.
0.0 ft• 11.0 ft. BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 11/22/21 Well lD# FGDLFPZ-19 11.0 ft• 30.0 It- BROWN SILTY SAND
5a.Well Location: 30.0 ff 34.0 ft. DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION 34.0 ft• 58.0 ft• PWR
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. f<,• I__
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address,City,and Zip
tr. ft. JAN s+ 4 207
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-40.0-46.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certification:
360 27' 30.45" N 80° 05' 58.18" W In,f,. r---
12/10/21
6.Is(are)the well(s)' OPermanent or ❑Temporary Signature of Certified Well Contractor Date
Hy signing this form,I hereby certify that the wells)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 drat a copy
1J'this is a repair,Jill out known well construction in/ormation and explain the nature o/'the ofthis record has been provided to the well owner.
repair under 121 remarks section or on the back q/'this Jornt.
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: 58•0 (ft.)
F'or multiple wells list all depths#*dierent(example-3 ct 200'and 2@I00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: S2.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if 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-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
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13b.Disinfection type: Amount:
Revised 6-6-2018
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources
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