GW1-2022-07393_Well Construction - GW1_20220809

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES is -
Well Contractor Name FROM TO I DESCRIPTION
f .
A - 2581 t. ft
tr. rt.
NC Well Contractor Certification Number
15.'OUTER CASING for ioulti-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM To DIAMETER THICKNESS MATERIAL
ft. ft. � in
Company Name
16.INNER CASING OR. BING eotherieal closed-loci
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable ivell construction permits(i.e. UIC,County,Stale,variance,etc.) 0.0 ft. 110.0 ft. 6.0 +'nSCH 40 PVC
3.Well Use(check well use): ft. ft.
Water Supply Well: 17:-SCREEN
FROM TO DIAMETER: SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 110.0 if 130.0 ft' 6.0 1O• .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>100000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 20.0 1" AQUA GUARD SLURRY
15Monitoring ❑Recovery
Injection Well:
tt. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVELPACK ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 25.0 ft. 135.0 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 421 Remarks) FROM TO DESCRIPTION color,hardness,soiUmck type,grain size,etc.)
0.0 fL 10.0 ft. BROWN SILTY SAND
4.Date Well(s)Completed: 07/28/22 Well ID# EX-67 10.0 It' 20.0 ft. TAN SILTY SAND
5a.Well Location: 20.0 fL 47.0 1" PWR
BELEWS CREEK STEAM STATION 47.0 ft• 135.0 ft• ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address,City,and Zip ft. ft.
STOKES 21.REMARKS t
Coven BENTONITE SEAL•-20.0-25.0 FEET
Y Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: SUMP- 130.0- 131.0 FEET ^s+;• ..-M_
(if well field,one lat/long is sufficient) 22.Certification:
928765.2122 N 1681162.289 W �' ' 08/01/22
6.ls(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC.02C.0100 Well Construction Slandards and that a copy
it this is a repair,fit/out known well construction infornmtion and explain the nature of the ofthis record has been provided to the svel/owner.
repair under;2l remarks section or on lire 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 1 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: 130.0 (ft)
l,or multiple wells list all depths ifdierent(example-J a 00'and 1Ca 100') Submit this GW-1 within 30 days of well completion per the following:
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10.Static water level below top of casing: 69.0 (ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
if water level is abore 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)
AIR Program, 1636 MSC,Raleigh,NC 27699-1636
12,Well construction method: 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
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FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GP)
13a.Yield(gpm) Method of test: ):Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,!NC 276997611
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13b.Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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