GW1-2022-06852_Well Construction - GW1_20220720

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS lA.WATER ZONES"
Well Contractor Name " FROM ft. TO ft DESCRIPTION
A - 2581
ft. ft.
NC Well Contractor Certification Number 1s..OUTER CASING formulti-casW ells)OR LWER'if a licabie
GEOLOGIC EXPLORATION ;'16.INNEERCASIN
DIAMETER THICKNESS MATERIAL
ft.Company NameG OR TUBING eofherrualclased-coo2.Well Construction Permit#: DIAMETER THICKNESS MATERIAL
List all applicable we//constructionpermits(i.e.UiC,County,State,Variance,etc.) 0.0 ft 6.0 1° SCH 40 PVC
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: 17.SCREEN,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 120.0 ft' 140.0 ft, 6.0 1p.', .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. In
❑IndustriaUCommercial ❑Residential Water Supply(shared) '18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 30.0 ft, AQUA GUARD SLURRY.
(EMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19-SAND/GRAVEL`PAC K ifa licalile .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 35.0 fL 140:0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer '20.'DRILLING LOG attach`additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soll/rock type,grain size,etc.
0.0 fl• 11.0 ft• RED SILTY CLAY
4.Date Well(s)Completed: 06/02/22 Well ID# IW-13 11•0 ft- 24.0 It- BROWN SILTY SAND
5a.Well Location: 24.0 1- 29.0 ft ! TAN SILTY SAND
BELEWS CREEK STEAM STATION 29.0 ft• 62.0 ft- PWRy��
Facility/Owner Name Facility ID#(if applicable) 62.0 fL 140.6 ft' R ,14 ■ - t-
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft. 7
Physical Address,City,and Zip ft. ft.
STOKES 21i REMARKS,.,
County Parcel Identification No.(PIN) BENTONITE SEAL•-30.0
rm v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
928758.1407 N 1681293.790 06/09/22
6.Is(are)the well(s)• 29Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify'rhat the we//(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or INNo 15A 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 of the ofihls record has been provided to the ire//owner.
repair under P21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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
9.Total well depth below land surface: 140.0 (ft.)
For multiple wells list all depths ttl`diferent(example-3 r@t 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 50.5 (ft) 24a. For All Wells: Original form io Division of Water Resources (DWR),
If water 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 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 olI 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,16I1 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test
13b.Disinfection type: Amount:
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20 t 8