GW1-2022-07379_Well Construction - GW1_20220809

F
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.
rt. ft.NC Well Contractor Certification Number '15.,OUTER CASING,foe multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I in.
Company Name t
16:INNER'CASING OR TUBING 'eothertnal closed-loon)
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc) 0.0 ft. 130.0 ft. 6.0 In' SCH 40 PVC
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 130.0 ft• 150.0 ft• 6.0 "' .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> 100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 20.0 ft- AQUA GUARD SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL-PACK if o licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 25.0 ft- 155.0 ft- 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#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain sin,etc.
0.0 ff• 9.0 ft. RED SILTY CLAY
4.Date Well(s)Completed: 07/27/22 Well ID# EX-19 9.0 R. 17.0 ff• BROWN SILTY SAND
5a.Well Location: 17.0 ft' 25.0 ft' TAN SILTY SA
BELEWS CREEK STEAM STATION 25.0 ft- 60.0 ft- PWR �" `m- s _,•,
Facility/Owner Name Facility ID#(ifapplicable) 60.0 ff• 155.0 ff- ROCK AUG
��
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address,City,and Zip ft. ft Inr`Ci?:a.Sv1 r r; 4rg Unit
STOKES ..21:REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL-20.0-25.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
SUMP- 150.0- 151.0 FEET
(ifwell field,one Iat/long is sufficient) 22.Certification:
928655.5190 N 1681102.907 w - 08/01/22
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,l hereby certt�that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.0100 or 15A NCAC 01C 10100 Well Construction Standards and that a copy
lj'this is a repair.fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 4'21 remarks section or on the back ofthis form.
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 additional well construction info
construction,only I GW-I 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: 150.0 (ft.)
Far multiple wells list all depths ifd�ftrent(example-3 a 200'and 2 rt 100') Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top ofeasing: 56.51 (ft) 24a. For All Wells: Original forth to Division of Water Resources (DWR),
lfwater 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 DiWR,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!100,0"GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,�NC 27699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018