GW1-2022-06853_Well Construction - GW1_20220720

l
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.-WATER ZONES�-
ROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 2581 ft. ft.
NC Well Contractor Certification Number YS.OUTER CASING for mu1N-cas'ed'wells OR.LiNER'if e' licable
GEOLOGIC EXPLORATION FROM . TO DIAMETER_ THICKNESS MATERIAL
ft,
Company Name 16.INNER CASING`OR TUBING' eothemal closed-lob
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits r.e.UIC,County,State,Variance,etc.) 0.0 f. 90.0 ft' 6.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
. 97.SCREEN,
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 90.0 ft• 110.0 ft' 6.0 to .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in,
❑IndustriaVCommercial ❑Residential Water Supply(shared)
IB..GROUT
❑lrri ation ❑Wells>100,000GPD FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 20.0 ft- AQUA GUARD SLURRY
IEMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
.1%SANDIGRAVEL PACK if applicable),
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 25.0 It- 110.0 ft• 20-40 FINESILICASAND
❑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,soil/mck type,gmin size,etc.)
0.0 ft- 8.0. ft- RED SILTY CLAY
4.Date Well(s)Completed: 06/01/22 Well ID# IW752 8.0 ft- 19.0 ft- BROWN SILTY SAND
5a.Well Location: 19.0 ft• 21.5 ft- TAN SILTY SAND
BELEWS CREEK STEAM STATION 27.5 ft- 40.0 ft- PW
Facility/Owner Name Facility ID#(if applicable) 40.0 ft- 110.0 ft- RO
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address,City,and Zip ft. ft.
STOKES 21:'REMARKS. r-7 nn
raw t aas e r�f
BENTONITE SEAL-•20.0-7t$B.FET)T; ,al D7t '�si�l I i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
928657.3600 N 1681230.529 W ;,,. r-
06/09/22
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,i hereby cert6 that the well(s)was(were)constructed in accordance wiih
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or ISA NCAC 01C.0100 Well Construction Standards and that a copy'
If this 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 i.21 remarks section or on the back of this form. I
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 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 (ft)
Far multiple wells list al/depths ifditfereht(example-3 a 100'and 1@100) Submit this GW-1 within 30 days of well completion per the following:
51.5 24a. For All Wells: Original form Ito Division of Water Resources (DWR),
10.Static water level below top of casing: VO Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"r I '
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 over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield m Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
(gP )
i
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018