GW1-2022-07075_Well Construction - GW1_20220729

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
Well Contractor Name
FROM
ft. TO ft. DESCRIPTION
A - 2581
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) 0.0 ft. 90.0 ft. 6.0 r"' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 90.0 ft. 110.0 ft- 6.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPP1Y(single)) ft. I ft. in.
❑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 ft. AQUA GUARD SLURRY
(EMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge CI Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 25.0 ft. 115.0 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 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.)
0.0 ft. 13.0 ft. BROWN SILTY SAND
4.Date Well(s)Completed: 06/23/22 Well ID# IW-3 13.0 ft. 25.0 ft. TAN SILTY SAND
5a.Well Location: 25.0 ft' 50.0 ft' PWR
BELEWS CREEK STEAM STATION 50.0 ft• 115.0 ft• ROCK
Facility/Owner Name Facility lD4(if applicable) ft. ft.
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:
928175.2816 N 1681142.195 W 52 Sn;,-;- 11M1,T---
06/27/22
6.Is(are)the well(s): (EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this forin,1 hereby certify that the,rell(s)iva ,g rorral�ut(yj(in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 We!! or�C[ fCri »Srd)tdQr c rnfl�)!ix tip}
If[his is a repair,fill out brown well construction information and explain the nature ofthe ofthis record has been provided to the ivell owner. I..v +f �F LjV�t
repair under 1'21 renarky section or on the back of this form. 23.Site diagram or additional well details: J IJ r 2 n7�
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide addition l well�ot�tYz2on info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may alM.yW,f t pal gagges if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS DI Qll - unk
9.Total well depth below land surface: 110.0 (ft.)
For nuduple wells list all dept/rs ifdrfferent(example-3 a 200'and 1 rt 100') Submit this GW-1 within 30 days of well completion per the following:
107.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
W.Static water level below top of casing: (ft') Infonnation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f water level is abore casing,use"+"
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(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018