GW1-2022-09064_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 2581
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased we
OR LINER if ap tlicable
GEOLOGIC EXPLORATION SPP 20z FROM TO DIAMETER THICKNESS MAI ERIAL
ft. tt. in.
Company Name �Ir3i! - .
1 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit k: ' r V',";li, �L FROM TO DIAMETER THICKNESS MATERIAL
List oll applirohle:cell can.riruclion permiis(i.e.lllC,C'omrtr,Slate,Variance.e1c.) 0.0 ft- 140.0 ft• 6.0 in. SCH 40 PVC
3.Well Use(check well use): tr. R. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE 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 ft in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 20.0 fL AQUA GUARD SLURRY
mmonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquiter Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a illicable
❑Aquiter Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Storinwater Drainage 25.0 ft• 165.0 ft• 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 under
FROM TO DESCRIPTION color,hardness,soilhrock type, chin size,eu.)
tt21 Remarks)
0.0 ft- 13.0 ft• BROWN SILTY SAND
4.Date Well(s)Completed: 09/06/22 Well ID# EX-48 13.0 ft• 20.0 ft- TAN SILTY SAND
5a.Well Location: 20.0 ft' 45.0 ft' PWR
BELEWS CREEK STEAM STATION 4S.0 ft- 165.0 ft• ROCK
Facility/Owner Name Facility ID4(ifapplicable) ft. ft.
3195 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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: SUMP- 160.0- 161.0 FEET
(ifwell field,one lit/long is sufficient) 22.Certification:
928950.5695 �, 1681427.843 W ��-,- 09/12/22
6.Blare)the i%cll(s): OPermanent or ❑Temporary Signature ofCcoified Well Contractor Dale
Br signing this/itnn.l herrhp cerOJy that the me//(s):roc(mere)c onsirueved in accnrdonce o ith
7.Is this a repair to an existing well: 01'es or MNo l iA NCAC 02C.0100 or/5.4 NCAC 02C.0200 Well Coiuirucimn Standard,and that a copy
If this is a repair./ill out known melt construction irtliirmation and explain the noutre of fhe o/this record has been provided to the me/l otrner.
repair wider 421 remarks.section or on the back q/76is fitrnt.
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-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 INSTRucrIONS
9.Total well depth below land surface: 160.0 (ft-)
Vor muhiple mellr list all depths il'dillereni(eron+ple-?(e)200'and 2 100') Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: 37.29 (ft.) Information
For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
//,rarer level is obore easing.use"+"
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-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
Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13a.field(gpnt) k7ethod of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources{ Revised 6-6-2019
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