GW1-2022-07930_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 2581
rr. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased:wells OR LINER if a t ilieahle
GEOLOGIC EXPLORATION FROM To DIAMETER THICKNESS MATERIAL
ft. rt. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit 4: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable,roll cunstrue•rion permits(i.e. (11C,Comity.Sitne,I%ariance.cn<) 0.0 ft• 140.0 rt• 6.0 1 ' I SCH 40 PVC
3.Well Use(check well use): R. ff. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 140.0 ft' 160.0 ft' 6.0 in-
010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft R in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 20.0 ft• AQUA GUARD SLURRY
(51VIonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a ilicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer"rest ❑Stortmwater Drainage 25.0 ft- 165.0 rt• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) 01-racer 20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Heating/Cooling Return) ❑Other(explain under N21 Remarks) FROM To DESCRIPTION color,nmdnes:,soilhrock type, rain size.etc.
0.0 ft- 14.0 f` RED SILTY CLAY
4.Date Well(s)Completed: 08/1 0/22 Well ID# EX-61 14.0 f` 25.0 ft• BROWN SILTY SAND
ia.Well Location: 25.0 ft 62.0 ft' PWR
BELEWS CREEK STEAM STATION 62.0 f` 165.0 ft• ROCK
Facility/Owner Name Facility ID#(ifapplicable) R. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
t
Physical.Address,City.and Zip ft. ft.
STOKES 21.REMARKS n1
County Parcel Identification No.(PIN) BENTONITE SEAL-20V-' .'0 FrEFaTo,1'&6QG
SUMP 160.0- 161.0 FEET
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hat/long is sufficient) 22.Certification:
928523.3666 N 1680934.219 W
08/11/22
6. Is(are)the well(s): 15Permanent or ❑Temporary Signature of'C-enified Well Contractor Date
1i%si,gn/ae dn.,form,/hereby crriili•that the u•e//(c),roc('•ere)consiruc•ted m ae•enrrdonce utilr
7.Is this a repair to an existing well: ❑Yes or MNo 15.4 N!'gC'rl2(:'.0/llll ur/SA AY:�IC'U2t-';.0200 Hell Cu,avrurrian,Srandarr/s anJ rhw a copy
if rhi.s is a repoir,/ill nm knmrn a ell ton im,lion/nfinmtalmn r»,d espinin,tie nruure ably" of ilw record has been prurided to doe uv<l l M,ner.
repoir under•::2/remarks svcImn ur on dre back ol this fiu•n,.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Yells having the same You may use the back of this page 1to provide additional well construction ink)
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
160.0
9.Total well depth below land surface: (ft.)
1•hr mrdtip/c,rrlG'lisiall depths if r/rlli+rern(example-301200 and 21//00') Submit this GV1'-I within 30 days of well completion per the following:
10.Static water level belo%top of casing: 64.0 24a, For All Wells: Original fonii to Division of Water Resources (DWR).
ft.)n�amr/rrr/is nhurr ru.ria,+;,me Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
..� (
11.Borehole diameter: 10.0 (in) 24b. For Injection Wells: Copy toDWR, Underground Injection Control (IIJC)
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
i
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.\'icld(gpm) Method of test: `
Permit Program. 1611 MSC,Raleigh i_NC 27699-1 6 1 1
I
13b.Disinfection type: Amount:
Form GU'-I North Carolina Department of Environmental Quality-Division of'Water Resources Revised 6-6-2018