GW1-2022-07222_Well Construction - GW1_20220729

(RECORD GW-1 For Internal Use Only:
WELL CONSTRUCTION y
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 ft TO ft. DIAMETER in. THICKNESS - MATERIAL
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 ft• 140.0 ft- 6.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 140.0 ft• 160.0 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
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 20.0 ft- AQUA GUARD SLURRY
15Monitoring ❑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 I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 25.0 ft, 165.0 ft 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additionalaheets if necessary).'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 ft 7.0 fL BROWN SILTY SAND
4.Date Well(s)Completed: 06/29/22 Well ID# EX-58 7.0 ft• 21.0 ft• TAN SILTY SAND
5a.Well Location: 21.0 fl• 39.0 ft- PWR
BELEWS CREEK STEAM STATION 39.0 ft 165.0 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 2L REMARKS
County Parcel identification No.(PIN) BENTONITE SEAL-20.0-25.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: SUMP- 160.0-161.0 FEET
(ifwell field,one latllong is sufficient) 22.Certification:
928265.4717 N 1680863.055 Nt 0%w
_ 07/06/22
6.Is(are)the well(s): iaJPermanent or ❑Temporary Signature of Certified Well Contractor i
i
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance iviih
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or ISA NCAC 02C.0100 Well ConS�rpptiotStalatlhl tt n/that a copy
ljthis is a repair,fill out known ivell construction information and explain the nature of the of this record has been provided to the well owner. JJ JJ LL LL [L�U1 L
repair under`'21 remarks section or on the back of this forn.
23.Site diagram or additional well detaiW.lkfgrta;jp;I (pr40zpyj..,g URA
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide addittilaj (Mstruction info
construction,only I GW-1 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
9.Total well depth below land surface: 160.0
For multiple wells list all depths ifeli ferent(example-3 ae200'and 2 r1 100) Submit this GW-1 within 30 days of well completion per the following:
89.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijwater level is above coring,use"+"
11.Borehole diameter: 10•0 (in) 24b.For Infection 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:
Font GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018