GW1-2022-06847_Well Construction - GW1_20220720

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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BRIAN THOMAS 14.`NATERZONEs _
Well Contractor Name FROM TO DESCRIPTION -
ft.
A - 2581
NC Well Contractor Certification Number 15:OUTER CASING for mtilh cased wells'OR LINER if .a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I in.
Company Name ,, -
I6;INNER'CASING.OR TURING` eotliermal closed-too ..
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well cons•tructionperntits(i.e.UIC,County,State,Irariance,etc.) 0.0 ft. 95.0 ft- 6.0 i in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
❑Agricultural DMunicipal/Public 95;0 fL 115.0 ft' 6.0 in.
1 .010 SCH 40 PVC
❑Geothermal(Heating/cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Coimmercial ❑Residential Water Supply(shared) 'is.GROUT.
❑lrrl ation ❑Wells>100,000 GPD FROM TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - 0.0 ft• 20.0 ft- AQUA GUARD SLURRY
(EMonitoring ❑Recovery ft. ft.
Injection Well:
ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
''19.PSAND/GRAVEL.PACK ifa,.licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StonmwaterDrainage 25.0 fr 120.0 ft• 20-40'. FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20..EiRiLLINGI.OG attach idditidr al-ilieets ifnecessa
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) FRorvl To DESCRIPTION color,hardness,soiVrock e,grain size,etc.)
0.0 ft 7.0
ft. RED SILTY CLAY
4.Date Well(s)Completed: 06/17/22 Well ID# IW-49 7.0 ft- 23.0 ft. 'BROWN SILTY SAND
5a.Well Location: 23.0 ft• 25.0 ft' TAN SILTY SAND
BELEWS CREEK STEAM STATION 25.0 fL 70.0 ft- PWR_
70.0 ft 120.0 ft i. O fP�k 1
Facility/Owner Name Facility ID#(ifapplicable)
`L r
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address,City,and Zip
STOKES %-2I.'tREMARICS " ;t..
BENTONITE SEAL-20.0-25
County Parcel Identification No.(PIN) Y f linAdc y,Nri, ,,v v,I l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
928457.8037 N 1680984.722. W
06/24/22
6.Is(are)the well(s): OPertnanent or ❑Temporary Signature ofCerti6ed Well Contractor Date
By signing this•form,I hereby certify that the ivel/(s)ryas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe oj'this record has been provided to the well owner.
repair under 421 rennarks-section or on the back oj'this fora.''=
23.Site diagram or additional wellidetails:
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
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9.Total well depth below land surface: 115. (ft,) Submit this GW-1 within 30 days of well completion per the following:
For multiple welly list all depths iJdifjerent(example-J a_00'and 2@100)
77.0. 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
if eater level is above casing,use"+" I
11.Borehole diameter: 10.0 (i») 24b. For Injection.Wells:Copy to DR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27W699-1636
12.Well construction method: AIR i ,
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,efc.) 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)
Permit Program,1611 MSC,Raleigh;NC; 27699-1611
Mcthad of test:
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13b.Disinfection type: Amount
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Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 6-6-2018
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