GW1-2022-09086_Well Construction - GW1_20220926

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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I.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES l
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 2581
NC Well Contractor Cutification Number 15.OUTER CASING for multi-cased;wells OR LINER if a rlicable)
GEOLOGIC EXPLORATION `'
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name -
2022 16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: ^b_.. FROM TO DIAMETER THICKNESS MATERIAL
Liss ol/applicable yell cons iniclion permits(i.e.lllC.l'ouniq•..Sinter-I(nCiunc¢•.,e.�c�,) 0.0 ft. 90.0 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 90.0 ft- 110.0 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 ft. AQUA GUARD SLURRY
29Monitoring ❑Recovery R. fr.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a,rlicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 25.0 ft. 115.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control D. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardness,soil/imck type, rain size,etc.
0.0 ft• 8 0 fL BROWN SILTY SAND
4.Date Well(s)Completed: 09/1 4/22 Well ID# IW-27 8.0 fr• 18.0 ft. TAN SILTY SAND
5a.Well Location: 18.0 ft. 24.0 ft' PWR
BELEWS CREEK STEAM STATION 24.0 IL 11S.0 ft• ROCK
Facility/Owner Name Facility IDk(it'applicable) fL ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address.City.and Zip ft. ft.
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:
(if well field,one]at/long is sufficient) 22.Certification:
928985.7420 N 1681255.205 �,�, �l�.r--
09/19/22
6.Is(are)the well(s): (91'ermanent or ❑Temporary Signature of Certified Well Contractor Date
Hv sigohkg(his,/in•n,.l hereby certi/v Ihau the well(s)was(sere)rnro'u ucued in occnrdowce with
7.Is this a repair to an existing well: 01'es or ONo 15,4 N('A(01('.0100 or 15A NC:A('02(-'.01110 Well('onctntctin)t.l7an(lcrrdv and that a cnpi
ll this is o repair.fill owl known it construction in/urination and e.vplam the moire o/the q/Ihi.s record has been provided h,d,e it owner,
repair under Jl retnarks.section or on d,e back q/(1his Jarnu.
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 1111b
construction.only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessan
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 110.0 (ft.)
/hor tnthiple frets/is/all depth., /'di/!i'rr,a(eramph-3 n,1o0'and 1(ot,/00') Submit this G11'-1 within 30 days of well completion per the following:
10.Static water level below top ofcasing: 36.25 24a. For All Wells: Original form to Division of Water Resources (DWR).
l(n'ater lorel is abate caring,use ,_
(ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: 10.0 (in) 24b. For Infection 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 ofthe county where installed
FOR 11'ATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh;NC 27699-16 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018