GW1-2022-07218_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
fr. fr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased ells), LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ire/1 construction permits(i.e.UIC.County,Stale,Variance,etc.) 0.0 ft. 150.0 rt' 6.0 1°' SCH 40 PVC
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 150.0 rr. 170.0 rr. 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>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 1` 20.0 ft. AQUA GUARD SLURRY
IMMonitoring ❑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 ❑StormwaterDrainage 25.0 ft. 17S.0 rt. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG'attach additionahsheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,saillnek type,gmin size,etc.)
0.0 ft. 16.0 ft. RED SILTY CLAY
4.Date Well(s)Completed: 07/07/22 Well ID# EX-64 16.0 ft. 25.0 1" BROWN/TAN SILTY SAND
5a.Well Location: 25.0 rt' 69.0 f- PWR
BELEWS CREEK STEAM STATION 69.0 ft- 175.0 rt. ROCK
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address,City,and Zip
rt. ft.
STOKES .21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-20.0-25.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: SUMP- 170.0- 171.0 FEET
(ifwell field,one lat/long is sufficient) 22.Certification:
928601.3146 N 1680912.842 W Glw•-
07/18/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cerlijy that the wel(s)was(irere)consiructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
!f this is a repair,Jill out known ire//construction information and explain fine nature of the of this record has been provided to the ire//owner.
repair under 921 remarks section or on the back of this form. p, 5
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 additigrtal will construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach iti _l ge���r?cessary.
drilled: 24.SUBMITTAL INSTRUCTIONS n
170.0 If>fiefr}a,tan����r+.tlz�az;.ng Urtg
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion perp'tltlt Y6T1'dviing:
For multiple wells li.st al!depths ifcfifferen((example-3 a 100'and 1 a 100�
54.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!ju•ater level is above 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 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018