GW1-2022-07394_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
BRIAN THOMAS ;14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. G
A - 2581
ft. ft.
NC Well Contractor Certification Number
15.:OUTER CASING for mvlti-eased wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. f4 in.
Company Name
16.INNER CASING OR TUBING' eothermal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Cotoay,State,hariance,etc.) 0.0 It- 140.0 ft• 6.0 t"' I SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17zSCREEN
FROM TO DIAMETER:' SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 140.0 f" 160.0 ft' 6.0 1" .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.,GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft, 20.0 fL AQUA GUARD SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL'PACK(if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 25.0 ft- 165.0 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,soitt-ck type, rain siu,etc.
0.0 n. 8.0 1- i BROWN SILTY SAND
4.Date Well(s)Completed: 07/25/22 Well ID# EX-72 8.0 ft• 15.0 tL TAN SILTY SAND
5a.Well Location: 15.0 tL 45.5 ft' PW
BELEWS CREEK STEAM STATION 45.5 rt• 165.0 ft• ROCK`,. . , t
Facility/Owner Name Facility IDN(if applicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 rt. ft.
Physical Address,City,and Zip ft. ft. !fl •i rfi 7� !�f?, .�.� ne
STOKES 21:REMARKSOIL
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
(if well field,one latAong is sufficient) 22.Certification:
928818.5735 N 1680948.875 Wes•:,- T`�' 08/01/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15No 15A NCAC 02C.0/00 or 15A NCAC 02C,.0200 Well Construction Standard%and that a cow
!f 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 1(21 remarks section or mt the back of this 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: 160.0 ft.)For multiple wells list a//depths l(Wi ferent(example-3 rt 100•and 1@100') ( Submit this GW-1 within 30 days of well completion per the following:
i
10.Static water level below top of casing: 65.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ij'waier 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-L'oop 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 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018