GW1-2022-06855_Well Construction - GW1_20220720

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
BRIAN THOMAS 14.WATER20NES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 2581
NC Well Contractor Certification Number lb>OUTER CASING'(for multi-casedswells ,OR'LINER'ifa 'licalile
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
INNER CASING OR TUBING; eothermal closed-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. 120.0 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 ❑Municipal/Public 120.0 1" 140.0 ft' 6 0 in., .010 SCH 40 PVC
El Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.`GROUT
❑Irrl ation ❑Wells> 100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 25.0 ft- AQUA GUARD SLURRY
(EMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK if applicable)
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❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 30.0 ft- 145.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothenal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa.
❑Geothermal(Heating/Cooling Return) ❑Other(explain tinder#21 Remarks) FROM TO DESCRIPTION color,hardness,soit/rock .e,grain size,etc.
0.0 ft• 17.0 ft- RED SILTY CLAY
4.Date Well(s)Completed: 06/08/22 . Well ID# IW-16 17.0 ft- 27.0 ft- BROWN SILTY SAND
5a.Well Location: 27.0 ft' 55.0 fr' TAN SILTY SAND
BELEWS CREEK STEAM STATION 55.0 ft' 61.0 ft' PWR
Facility/Owner Name Facility ID#(if applicable) 61.0 ft• 145.0 ft- ROCK
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address,City,and Zip ft. ft.
STOKES 21.`•REMARKS_`.:::, I. . , _ . .
County Parcel Identification No.(PIN) BENTONITE SEAL-25.0-30 0E€ , E� ,.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `
(if well field,one fat/long is sufficient) 22.Certification:
928880.2421 N 1681370.425 W
6.Is(are)the well(s)• I51'ermanent or ❑Temporary Signature of Certified Well Contractor Da12
By signing this form,I hereby certify that the ivell(s)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo !SA NCAC 02C.0l00 or!SA 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 ofthis record has been provided to the well owner.
repair under 921 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 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
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9.Total well depth below land surface: 140. (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 n 00'and 2@100)
43.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: A) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
0.0 24b.For Injection Wells: Copy toiDWR,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
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 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018