GW1-2022-07555_Well Construction - GW1_20220815

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: x ;
BRIAN THOMAS 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION '
A - 2581 a. ft.
fr. ft. D1?JQi'8OG
NC Well Contractor Certification Number
15.OUTER CASING for.multi-tased`we Its)OR'LWER'ifa licable
GEOLOGIC EXPLORATION FROM T DIAMETER THICKNESS MATERIAL
ft. in
Company Name ft.
16.,INNER CASING OR TUBING eothermal closed,loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 140.0 rt• 6.0 1O• SCH 40 PVC
3.Well Use(check well use): fr. ft. in.
Water Supply Well: 1Z SCREEN
FROM TO DIAMETER SLOT SIZE THtCIOVESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
140.0 160.0 6.0 .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft• ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 rr 20.0 rr AQUA GUARD SLURRY
Monitoring ORecovery rt• frInjection Well:❑A uifer Rechar a ft. tt.
q g ❑Groundwater Remediation
❑Aquifer Storage and Recovery OSalini Barrier [,FROM
9.SAND/GRAVEL PACK'if a licable.--
ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 25.0 ft- 165.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING LOG"attach additional sheets if necessary)
OGeothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soiVrock type,
rain size,etc.
0.0 rt• 18.0 ft. BROWN SILTY SAND
4.Date Well(s)Completed: 08/05/22 Well ID# EX-14 E2.O
32.0 ft- TAN SILTY SAND
5a.Well Location: ft
51.0 fr' PWR
BELEWS CREEK STEAM STATION 165.0 rt ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 e. ft.
Physical Address,City,and Zip fr. ft.
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STOKES u:REMARics
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]at/long is sufficient) 22.Certification:
928244.5851 N 1681011.569 W ,
08/08/22
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,f hereby certify that the We/M)was(were)construcled in accordance with
7.Is this a repair to an existing well: OYes or I9No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/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 lit/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: 160'0
For multiple wells list all depths iJ'J�erent(example-3@200'and 2@/00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 25.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lJlraierlevel is above caring,use Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 10.0 (in) 24b. For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
AIR
(12.i.e.auger,rotary,cable,direct push,etc.) Program, 1636 MSC,Raleigh,NC 2769971636
Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells•Copy to the
county environmental health department or the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells l
producine over 100 000 GPD Copy to DWR,CCPCUA
(gP ) Method of test:
13a.Yield m Permit Program,1611 MSC,Raleigh,NC 27699- 661 I
13b.Disinfection type: Amount
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018