GW1-2022-06844_Well Construction - GW1_20220720

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS :'14.WATER ZONES" '
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 2581
ft. ft. f
NC Well Contractor Certification Number 15.OUTER CASING.'for multi=cased wells OR LINER.i£a`"licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
tr. ft. in.
Compyny Name
16.INNER CASING OR TUBING'eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,variance,etc.) 0.0 ft• 95.0 ff 6.0 tn' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
-..-
Water Supply Well: FROM EEN '
FROM TO DIAMETER- SLOT SIZE THICKNESS M1tATERIAL
❑Agricultural ❑Municipal/Public 95.0 ft. 1115.0 ft' 6.0 1°' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT.
❑irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 20.0 ft- AQUA GUARD SLURRY
[EMonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL-PAC if applicable)
"
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑AgttiterTest ❑Stormwater Drainage 25.0 ft 120.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. R.
❑Geothermal(Closed Loop) ❑Tracer '26.,DRILLING LOG'attach additional sheets if necessary),-",
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FRONT TO DESCRIPTION color,hardness,soiltrock type,ginin size,etc.)
0.0 ft. 8.0 ft• RED SILTY CLAY
4.Date Well(s)Completed: 06/16/22 Well ID# IW-10 8.0 ft. 24.0 ft• BROWN SILTY SAND
5a.Well Location: 24.0 ft' 45.0 ft' TAN SILTY SAND
BELEWS CREEK STEAM STATION 45.0 ft• 63.0 fL PWRT,gg
Facility/Owner Name Facility ID9(if applicable) 63.0 ff 120.0 ff RQL C°" h S" V'
3195 PINE HALL ROAD BELEWS CREEK 27009 fr. ft. 9
Physical Address,City,and Zip
ft. fr.
STOKES 21:REMARKS.
u �r t UN,i
BENTONIfE SEAL 20.0-25 0 EFrT^•+ )6L,'�'��i'v
County Parcel Identification No.(PiN) c n•� �t er�-•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
928563.0071 N 1681095.571 Wr--
06/24/22
6.Is(are)the well(s): (!]Permanent or ❑Temporary Signature ofCertifred Well Contractor Date
By signing this forte,/hereby certify that the wells)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IENo 15A NCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction infbrinaiion and explain the nature ofihe ofthis•record has been provided to the well owner.
repair under,21 reinarks section or on the back of this•forin.
i
,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-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: 115.0 (ft.)
F-or multiple sells list all depths tfdtffereni(example-3Q200'and 2@a 100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 56.0 (ft) 24a• For All Wells: Original forin to Division of Water Resources (DWR),
m lnforation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/jwater level is abore casing,use•'+" i
10.0 24b.For Injection 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
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.field(gpm) Method of test: ;
13b.Disinfection type: Amount:
Font G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6 6-2018