GW1-2022-06846_Well Construction - GW1_20220720

WELL CONSTRUCTION RECORD(GW-.1) For Internal Use Only:
1.Well Contractor Information:
„B RIAN TH O MAS 14.WATEWZONES }
FROM - TO- aDESCRIPTION
Well Contractor Name ft. ft. '
A - 2581
ft. ft.
i
NC Well Contractor Certification Number .15 OUTER.CASING 116imultr.66ed4ells0R LINER'ira"licatile
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I in.
Company Name -
16 INNER'CASING OR:TUBING "'eothiFnia closed loo" c_.
2.Well Construction Permit#: FROM. TO DIAMETER' THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC County,State,Variance,etc.) 0.0 ft. 90.0 ft. 6.0 '1°' SCH 40 PVC
j 3.Well Use(check well use): fr. ft. in.
-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 90.0 ft. 110.0 ft. 6.0 1°' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
[ Industrial/Commercial ❑Residential Water Supply(shared) a8:_GROUT _
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It, 20.0 ft• AQUA GUARD SLURRY
IMMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19i.SAND/GRpVEL.PACK'"if a"licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test DStormwater Drainage 25.0 ft- 110.0 ft. 20-40 ' FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer '.20:_DRILLING'L`OG.attacli addthonal's"heets'if necessa
❑GeothermaL(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness, :oillrock a rnur size,etc.
0.0 7.0 ft, RED SILTY CLAY
06
a.Date Well(s)completes: /01 2/2 - Well ID# IW-11 7.0 ft. 19.0 ft. i BROWN SILTY SAND
Sa.Well Location: 19.0 ft, 22.5 r; r,h �° y'SILTY SAND
BELEWS CREEK STEAM STATION 22.5 ft• 41,0 •f .. ' "` _R PWR
Facility/Owner Name Facility ID#(if applicable) 41.0 ff 110.0 ft J J L 750 2022 ROCK
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft. I
Physical Address,City,and Zip ft. ft `rJ1LW 10117' _ �� f 9 a
STOKES' ;�21.,REMARKS? �, ��•� t--
County Parcel Identification No.(PIN) ' BENTONITESEAL 20.0J .0 F
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latnong is sufficient) 22.Certification: ! I `�, �7' Tcs)
928622.9867 N 1681199.537 W -�- ilJ(` �/ �
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6.Is(are)the well(s): hJPerm_anent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fit!out known well construction information and explain the nature ofthe ofthis record has been provided to the iv/ell owner.
repair under#21 remarks section or on the back ofthis 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 l GW-l 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: 110.0
for multiple wells list all depths if'dierent(example-3 200'and 2@100') Submit this GW-1 within 30 days'of well completion per the following:
91.5 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
lfwater level is above casing,use"+"
100 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
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Producina over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: i
13b.Disinfection type: Amount:
Form G W-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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