GW1-2022-07223_Well Construction - GW1_20220729

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES.
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 2581
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for m -caed wells)
GEOLOGIC EXPLORATION M TO DAMETR
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 well construction permits(i.e.UIC,County,Stare,Variance,etc.) 0.0 ft- 80.0 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 80.0 ft- 100.0 ft' 6.0 1O' 010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑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 ft. 20.0 ft. AQUA GUARD SLURRY
Monitoring ❑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. 105.0 f-- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,ere.
0.0 ft• 13.0 It- BROWN SILTY SAND
4.Date Well(s)Completed: 06/30/22 Well ID# EX-60 13.0 ft• 2S.0 fL TAN SILTY SAND
5a.Well Location: 25.0 ft- 75.0 ft' PWR
BELEWS CREEK STEAM STATION 75.0 ft. 105.0 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
rt. ft.
STOKES 2L 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- 100.0- 101.0 FEET
(if well field,one lat/long is sufficient) 22.Certification:
928458.6039 N 1680831.570 W �jlr---
07/06/22
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,!hereby certify that the e (�a e led in accordance with
7.Is this a repair to an existing well: ❑Yes or 15No /SA NCAC 02C.0/00 or!SA NCAC 02C. 20Tt f�71 .a seri,n 'r mil d that o copy
lfthis is a repair,fill out known well construction information and explain the nature of die ofthis record has been provided to the well owner. f
repair under#21 remarks section or on the back ofthis form. JJ
23.Site diagram or additional well detail�s0l_ 2 9 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additiona��tff11��
Jel�construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).Y'blM. ,gUeA tp4Latldi�t nal pages if necessary.
drilled: �1.'��lg U itfr
24.SUBMITTAL INSTRUCTIONS OG
9.Total well depth below land surface: 100.0 (ft.)
For multiple wells list all depths ii(di erent(example-3(a 200'and 2 rt 100') Submit this GW-1 within 30 days of well completion per the following:
52.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
If unrer level is above casing,use"+"
f Static water level below top of casing: (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-I61 l
13b.Disinfection type: Amount:
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2019