GW1-2022-06845_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. %
NC Well Contractor Certification Number '15.OUTER CASING for multi-cased wells ORLINER ifa'`licable"
GEOLOGIC EXPLORATION FROM TO DIAMETER' THICKNESS MATERIAL
ft. ft. in.
Company Name
16:INNER CASING OR TUBING eother at closed-loo'
2.Well Construction Permit#: FROM TO DIAMETER , THICKNESS MATERIAL
List ali applicable,rell construction perutiis(i.e.UIC,County,State,Variance,etc) 0.0 ft. 120.0 ft. 6.0 ' in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Su Well: 17.SCREEN '
Supply FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 120.0 ft• 140.0 ft' 6.0 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>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 25,0 ft- AQUA GUARD _SLURRY
[EMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
d9.'SAND/GRAVEL PACK(if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDrainage 30.0 ft- 145.0 ft 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer .20 DRILLING LOG attach additional sheets if necessary)?,
FROM TO DESCRIPTION color,hardness,soiUrock e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
0.0 ft. 18.0 1- RED SILTY CLAY
4.Date Well(s)Completed: 06/13/22 Well ID# IW-14 18.0 ft. 27.0 ft. BROWN SILTY SAND
5a.Well Location: 27.0 ft' 62.0 ft' TAN SILTY SAND
BELEWS CREEK STEAM STATION 62.0 ft. 65.0 ft. PWR
Facility/Owner Name Facility ID#(if applicable) 65.0 ft. 145.0 ft' ��K�sZ d K
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft. V,� „ -�
Physical Address,City,and Zip ft. ft. J U 022
'STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL 25.0-30,0QET3iTEi�;d
VIt1UL;t*&,5M4J Ulf
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
928823.4757 N 1681306.652 Wljlkr�--
06/24/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(.)was(were)consinncted in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Yell Construction Standards and that a cope
IJ'this is a repair,fill out known well construction information and explain the nature ofthe of this record has beein provided to the well owner.
repair under 921 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: 140.0 (ft.)
For multiple,cells list all depths ifdii ferent(example-3 a 200'and 2ca 100') Submit this GW-1 within 30 days of well completion per the following:
4�7.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
f w Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If ater lore!is above casing,use j
11.Borehole diameter: 10.0 (11f) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-I636
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 27699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
,
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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