GW1-2022-09061_Well Construction - GW1_20220923

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES i
Well Contractor Name FROM TO DESCRIPTION
A - 2581
ft. ft.
NC Well Contractor Certification Number C r P J 2�2� 15.OUTER CASING for multi-cased wells OR LINER if a tlicable
GEOLOGIC EXPLORATION J FROM TO DIAMETER THICKNESS MATERIAL
t�l ft. ft. in.
Company Name
rt•t'`D; i?C 16.INNER CASING OR TUBING(geothermal closed-loo t
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable trell construction perions(i.e.UIC.Count),Stole. Variance.etc'.) 0,0 ft. 140.0 ft- 6.0 in- SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 140.0 ft' 160.0 R• 6.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 20.0 ft• AQUA GUARD SLURRY
[EMonitoring ❑Recovery ft. ft.
Injection Well:
tr. tr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if ti rlicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 25.0 ft• 165.0 ff• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain Linder#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rocky e,grain size,etc:)
0.0 fL 17.0 fr• RED SILTY CLAY
4.Date Well(s)Completed: 09/08/22 Well ID# EX-53 17.0 ft• 27.0 fL BROWN SILTY SAND
5a.\\tell Location: 27.0 a' 41.0 ft' TAN SILTY SAND
BELEWS CREEK STEAM STATION 41.0 ft- 53.0 ft- PWR
Facility/Owner Name Facility ID#(if applicable) 53.0 e• 165.0 fr• ROCK
319S PINE HALL ROAD BELEWS CREEK 27009
Physical Address,City.and Zip ft. ft.
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 20.0-25.0 FEET
SUMP - 160.0- 161.0 FEET
5b.Latitude and longitude in degrees/nlintltes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) 22.Certification:
928941.5682 N 168153S.266 \\; -- ' " 09/12/22
6.Is(are)the well(s)• OPermanent or 01'emporary Signature of Certified Well Contractor Date
By svening this lornt.l hereby certili'that(he mell(h)a as(were)constructed in accordanc0 with
7.Is this a repair to an existing well: ❑Yes or ONo 1.5.4 NC•AC 02C.0/00 or 15A NC AC 02C.0200 It-'ell Construction Standards and that it cops
11 this is it repair.Jill ow knatrn trell construction information and explain the nature o the nl'this record has been prorided to the trell corner.
repair under c71 reuuv-ks'section or on the hock ujdhir./ihrnh. '
23.Site diagram or additional well details:
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction into
construction.only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'Sce Over'in Remarks Box).You may also attach additional pages if necessan'.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 160.0 (ft.)
bor multiple.re//s list all deprh.c/fdiJ/ireni(example-3¢200'mud 2@10I1') Submit this G\\'-I within 30 days of well completion per the following:
40.35 24a. For All Wells: Original form to Division of Water Resources (DWR).
lU.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I%miner level is above casing!•use"a"
I
10.Q 24b. For Injection Wells:Copy toiDWR, Underground Injection Control(IUC)
IL Borehole diameter. (in.) 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,rotap-,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 27699-16 1 1
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6.2018