GW1-2022-07209_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
rt. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased, its)OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
rt. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-16613)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.U1C,County,State,Variance,etc.) 0.0 It- 70.0 ft- 6.0 in- SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 70.0 ft. 90.0 tt• 6.0 1 ' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.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
Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 25.0 ft• 95.0 fl• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. I ft.
❑Geothermal(Closed Loop) OTracer 20;DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) El Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soittmck type,gmin size,etc.
0.0 ft• 11.0 It. BROWN SILTY SAND
4.Date Well(s)Completed: 07/1 1/22 Well ID# IW-42 11.0 ft• 20.0 ft. TAN SILTY SAND
5a.Well Location: 20.0 ft. 50.0 1" PWR
BELEWS CREEK STEAM STATION 50.0 fl, 95.0 fr• 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:
927959.5753 N 1681138.248 W �ti;,.,, -
07/18/22
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the ivell(s)was(were) tme+�' r�a�c i nh.1
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consiruciion Standar and teat c'81' L. '
/J this is a repair,fill out known ivel/construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additional well details: J U L 2 9 :2022
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide addiio DWI I);�yp{is gg Unh
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovel in Remarks Box).You may also attac ittona� i-r}�cR�sar .
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 90.0 (ft.)
For multiple wells list all depths ifdifJeren[(example-3 a 00'and 2 tt 100') Submit this GW-1 within 30 days of Well completion per the following:
27.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
f water level is above casing,use'.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!f
11.Borehole diameter: 10.0 (in) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) .
Program, 1636 MSC,Raleigh,NC 27699-1636
]2.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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018