GW1-2022-07189_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 TO DESCRIPTION
ft. ft.
A - 2581
ft. ft.
NC Well Contractor Certification Number ,15.OUTER CASING for TR!!-cased Yells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICHIVFSS 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.UIC,County,State,Variance,etc.) 0.0 ff 80.0 ff 6.0 "' I 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/Pubhe 80.0 It. 100.0 ft. 6.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft• ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 20.0 ft• AQUA GUARD SLURRY
(EMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
,19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 25.0 ft• 105.0 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,soillrock type,gmin size,etc.
0.0 ft• 16.0 ft. BROWN SILTY SAND
4.Date Well(s)Completed: 06/29/22 Well ID# IW-7 16.0 ft• 27.0 ft- TAN SILTY SAND
Sa.Well Location: 27.0 ft' 55.0 ft' PWR
BELEWS CREEK STEAM STATION 55.0 ft- 105.0 ft. ROCK
Facility/Owner Name Facility ID#(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 la/long is sufficient) 22.Certification:
928339.6901 N 1680854.412 W n,�„ +�r--
07/06/22
6.Is(arc)the well(s)• INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the ivell(s)was(trere)constructer/in accordance with
7.is this a repair to an existing well: ❑Yes or 19No 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 inforuration and explain the nature of the 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 adds ioliE str I t n ED
construction,only 1 GW-I 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 JUL 2 9 .2022
0
9.Total well depth below land surface: 100. (ft.) N.
For multiple trells list all depths ifdierent(example-3«200'and 2@100') Submit this GW-1 within 30 days of well comps t�a l(�$jtr � URg
10.Static water level below top of casing:
32.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.)
lfwater 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 over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 11'Iethod of test: Permit Program,1611 MSC,Raleigh,NC 27699-161 I
13b.Disinfection type: Amount:
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018