GW1-2022-07224_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
A - 2581 ft. ft.
fr. fr.
NC Well Contractor Certification Number A5.OUTER CASING for multi-cased wells OR 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 well construction permits(i.e. UIC,County,State,Variance,etc.) 0.0 ft. 120.0 ft. 6.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
M SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 120.0 ft. 140.0 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) is.GROUT.
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 20.0 rt. 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 5ATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 25.0 ft• 14S.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(HeatinglCooling Return) ❑Other(explain tinder#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0.0 ft• 7.0 ft• BROWN SILTY SAND
4.Date Well(s)Completed: 06/30/22 Well ID# EX-62 7.0 fr• 15.0 ft• TAN SILTY SAND
Sa.Well Location: 15.0 ft. 58.0 ft' PWR
BELEWS CREEK STEAM STATION 58.0 ft- 145.0 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)
BENTONIfE SEAL-20.0-25.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: SUMP- 140.0- 141.0 FEET
(if well field,one latlong is sufficient) 22.Certification:
928447.3381 N 1680729.534 Wn;,,,t�J r,,r--
07/06/22
6.Is(are)the well(s)• (EPermanent or ❑Temporary Signature ofCertifhed Well Contractor pis Date
Hy signing this form,1 hereby certify that the ivell(s) 4tanst +Jika c r a with
7.Is this a repair to an existing well: ❑Yes or ONo l5A NCAC 02C.0l00 or!SA NCAC 02C.0200 WelttCoSs'4rim �a�n'dar 6 v 1 r,c a apv
lfthis is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks-section or on the back ofthis jornh. J U L 2 9 2022
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 pro itJee+additional well construction info
add'See Over'in Remarks Box).You ma �1sR�dtf� t�it(iFret' I a
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells ( y „ '�E• � �
Dl,tct/BOG
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 140.0 (ft.)
For nuduple u•e//s list all depths ifd jerent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 39.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
ljwater level is above casing,use"+"
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 county department of the where installed
P h'
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:
Fortn GW-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018