GW1-2022-07215_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 multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. it
Company Name
16.INNER CASING OR TUBING(geothermal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,Coun(K State,Variance,etc.) 0.0 ft. 64.0 ft. 6.0 tn' SCH 40 PVC
3.Well Use(check well use): ; ft. m in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICICIESS MATERIAL
❑Agricultural ❑Municipal/Public 64.0 f` 84.0 ft' 6.0 "' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustriaUCommercial ❑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
[EMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 25.0 ft• 89.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. I ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVmck type,gmin size,etc.
0.0 fit. 21.0 ft. BROWN SILTY SAND
4.Date Well(s)Completed: 07/06/22 Well ID# IW-29 21.0 ft- 35.0 f`• TAN SILTY SAND
Sa.Well Location: 35.0 ft' 47.0 ft' PWR
BELEWS CREEK STEAM STATION 47.0 ft. 89.0 fL 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) BENTONUE SEAL-20.0-25.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
928518.8093 N 1680688.193 W
07/18/22
6.Islam)the well(s): TPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing 1hi.s form,I hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONO ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the ive//owner.
r-a .' e i f repair under i'21 remarks section or nth the back oftihis joruh. q
23.Site diagram or additional well details: tL U 1
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attac gdditigiaP L ecessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
84.0 It1fCf91ia:liil l�f:::xJS++:.g Urx
9.Total well depth below land surface: (ft.) ��
1--or multiple wells list all depths fdifferent(example-3@200'and 2 a 100) Submit this GW-1 within 30 days of well completionl'p ' wving:
47.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:lfsrater lave/is above casing,use"+" (ft') 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) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Amount:
Form GW-1 - North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018