GW1-2022-06851_Well Construction - GW1_20220720

WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 2581 fr. ft
NC Well Contractor Certification Number AS.OU.TERCASING for,r°ult;-cased wells)OR LINER if a Ticible
GEOLOGIC EXPLORATION FROM TO DIAMETER THICINESS MATERIAL
ft. ft. I _
in.
Company Name
16�INNER•CASING'ORTUBING` e6thermalclosed-loo - .
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. 00.0 ft 6.0 1° SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water'Supply Well:
. FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 90.0 ft. 110.0 ff 6.0 1°' .010 SCH 40 PVC
❑Geothenmal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT,METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft 20.0 1- AQUA GUARD SLURRY
l9Monitoring ❑Recovery ft. ft
Injection Well:
ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a "licable.,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 25.0 f- 110.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20 DRILLING LOG attach additional sheets if necessary),
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,saitirack type,grain s m,etc.
0.0 ft- 5.0 ft- RED SILTY CLAY
4.Date Well(s)Completed: 06/03/22 Well ID#. IW-12 5.0 ft- 18.0 ft• BROWN SILTY SAND
5a.Well Location: 18.0 ft' 25.5 ft' j TAN SILTY SAND
BELEWS CREEK STEAM STATION 25.5 ft' 50.0 ft' PWR
Facility/Owner Name Facility ID#(if applicable) 50.0 ft. 110.0 ft. ROCK
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address,City,and Zip ft. ft.
STOKES :21:REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL-20.0-25.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
928693.8768 N 1681258.956 W - '" 06/09/22
6.Is(are)the well(s)' MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the irell(s)was(were)constructed in accordance with
7.Is this a repair to aft existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 110.0 (ft)
Tor multiple wells list all depth's ifdii ferent(example-3 tr 00'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of easing: 53.5 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
ljuarer level is above casing,use^+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 10.0 (in) 24b.For Injection Wells:Copy to'DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR I '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
r ;
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 27699-161 I
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13b.Disinfection type: Amount: �T
JUL 2 0 2022
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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