GW1-2022-07208_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
A - 2581
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a lieable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNEILCASING OR TUBING Netithermal closed-loo
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0,0 ft• 65.0 ft. 6.0 in. SCH 40 PVC
3.Well Use(check well use): ft. it. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 65.0"' 85.0 ft. 6.0 1O' .010 SCH 40 PVC
OGeothetmal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑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- 20.0 ft• AQUA GUARD SLURRY
®Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK 1'a lieable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 25.0 ft- 88.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attacti additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) FROM TO DESCRIPTION color,hardness,soiUruck type,grain sin,etc.)
0.0 ft• 17.0 ft. BROWN SILTY SAND
4.Date Well(s)Completed: 07/1 5/22 Well ID# IW-36 17.0 ft. 30.0 fL TAN SILTY SAND
5a.Well Location: 30.0 fL 62.0 ft' PWR
BELEWS CREEK STEAM STATION 62.0 ft- 88.0 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 lat/long is sufficient) 22.Certification:
928697.9889 N 1680941.041 W 07/18/22
6.is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed itr accordance with
7.Is this a repair to an existing well: ❑Yes or 15No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If Il s is a repair,f/l out known well construction information and explain the nature of the of this record has been provided to the well owner I r-- "-N
repair under i:21 remarks section or on the back ofthis form. 9 �j U
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 addition f ell C)bn nto
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach aditfdnal ags iW.ary.
drilled: 24.SUBMITTAL INSTRUCTIONS IntcfAA;@:on Pr..�5 - g Und
9.Total well depth below land surface: 85.0 (ft.) 1 '
DA Q/3C1t:
For multiple wells list all depths ifdii ferent(example-3@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: 50.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwarer 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]00,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1
13a.Yield(gpm) Method of test: 611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018