GW1-2022-08736_Well Construction - GW1_20220826

WELL CONSTRUCTION.RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
ft. ft.
A - 2581
fr. R.
NC Well Contractor Certification Number 15.OUTER CASING forlti-cased wells)OR LINER if a licable)mu
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
/.i.rt all applicable well con.rtruc•tion pe,•nritr(i.e.(./lC,Counly,.State,Variance,etc.) 0.0 ft. 70.0 ft. 6.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, ft. in.
70.0 90.0 6.0 .010 SCH 40 PVC
❑Geothermal(Fleating/Cooling Supply) ❑Residential Water Supply(single) ft. R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD B AMOUNT
Non-Water Supply Well: 0.0 ft• 20.0 ft. AQUA GUARD SLURRY
INMonitoring ORecovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM 1'O MATERIAL EMPLACEMENr AIETHOD
❑Aquifer Test ❑Stormwater Drainage 25.0 ft. 95.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. I ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary'
FROM TO DESCRIPTION(color,hardness,soil/rock type. nin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain tinder#21 Remarks)
0.0 ft• 8.0 ft. RED SILTY CLAY
4.Date Well(s)Completed: 08/16/22 Well ID# IW-40 8.0 ft• 18.0 ft. BROWN SILTY SAND
5a.Well Location: 18.0 ft' 30.0 ft' TAN SILTY SAND
BELEWS CREEK STEAM STATION 30.0 ft. 34.0 ft. PWR
Facility/Owner Name Facility I D#(ifapplicable) 34.0 ft. 95.0 ft. ROCK
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address,City, ft. ft.
y t}',and Zip
STOKES 21.REMARKS
• County Parcel Identification No.(PIN)
BENTONITE SEAL- 20.0-25.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one[at/long is sufficient) 22.Certification:
928826.6180 N 1681098.495 W -- �j��•r 08/22/22
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature ofCenified Well Contractor Date
Hy signi,rt;this for,u,l hereby c•erllfy that the ire/l(s)was(were)cw,.rvacteJ in ae•rardanc•e with
7.Is this a repair to an existing well: OYes or [TNo I5A NCAC 02C'.0100 or 15A NCAC 02C.0200 11'e//Cnns'uuctinn.lYnndnrds and that a
1f(hie'is«repair,fill out known,well construction intbrmatioa and e.tplahl the aot«re o%the q/7his record has been prorided to the well owner.
repair warder tv2/rentarkr.section or air the hack c fthis./bra.
23.Site diagram or additional well details: ' r* !a"
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well�onsfra 0n info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional paRTI if ng�e�SaryOq�
ff11
drilled: 24.SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface: 90.0 (ft.) ��_ _ ,;. za ;ca;j ;�UG;I
jrrii,i,.�•
Fornn,hi/r,rellr/i.rtnl/de,risidi ere•nt rcnnr,le-9«_oo'cu,d_, l00' Submit this AA•ithin30daysofyA•elleompletionpe e o oyA;rng.� t
p / l lI ( l C' 'G� ) ...�Ali i.Ov
10.Static water level below top of easing: 59•0 (ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
l%,rater lrrel is nhnrc c'nvlag,Ave•­
Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 10.0 (in) 24b. For Injection Wells: Copy to DWR,Underground hijection 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 1VELLS ONLY: 24d.For Water Welts producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: `
Permit Program, 1611 MSC,Raleigh,NC 27699-161 I
13b.Disinfection type: Amount:
Form 0W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018