GW1-2022-09087_Well Construction - GW1_20220926

I,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES I
FROM TO I DESCRIPTION
Well Contractor Name I.
ft. ft.
A - 2581
ft. ft.
NC Well Contractor Certification Number Imo+ 15.OUTER CASING for multi-cased'wells OR LINER if a licable)
GEOLOGIC EXPLORATION T `� ' '"°i � '^ FROM TO DIAMETER THICKNESS MATERIAL
�. w.a _ bra
ft. in.
Company Name ^
p 202� 16.INNER CASING OR TUBING r eothermal closed-loop
2.Well Construction Permit#: r 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable trell co„slruction permits(i.e. IW (Rmm�t_$tare,I!griance,etc.) 0.0 tt- 120.0 R. 6.0 i"' SCH 40 PVC
71,Crir:,. 0 ft. ft. in.
3.Well Use check well use): ';'`; 4 art^ ml
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
OAgricultural ❑Municipal/Public 120.0 ft' 140.0 rt. 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
❑lfrl atioll ❑Wells> 100,000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 20.0 fL AQUA GUARD SLURRY
OMonitoring ORecovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a t licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage 25.0 rt• 145.0 rr• 20-40 FINE SILICA SAND
❑Experimental Technology OSubsidenceControl
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM 1.0 DESCRIPTION coloq hardness,soilhvck type,grain size.etc.
0.0 rt• 5.0 f'. BROWN SILTY SAND
4.Date NVell(s)Completed: 09/1 3/22 Well ID# IW-26 5.0 e• 19.0 ft. TAN SILTY SAND
5a.Well Location: 19.0 rt' 21.0 rt' PWR
BELEWS CREEK STEAM STATION 21.0 rr• 145.0 e• ROCK
Facility/Owner Name Facility ID!!(if applicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. e.
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:
(it\veil field,one lit/long is sufficient) 22.Certification:
928957.8943 N 1681230.017 W 3ortz7- � 09/19/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature ofCertihed Well Contractor Date
Bj stipung this/i,rn,,l lrerehv eenJi•flan iln•a e//(cJ,vac(irereJ roreciructud in accordance yid,
7.Is this a repair to an existing well: ❑Yes or ONo I5.4 NCAC 02C.0100 or 114 NCAC 02C:•.0200 Well Construction Siondordc and dial a coin
/f this iv a repair till out knmrn,cell consiruclion in/brnratioo and explain the nature o/the ojthis record has been provided to the it nn ner.
repair under-2/renmrkv sue-ion or on the hack ol'thir.1brin.
23.Site diagram or additional well details:
8.For Geoprobe/DP r or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction infix
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
9.Total well depth below land surface: 140.0 (ft.)
hbr nnthiple,reNs list all depths i/'dillirent(example-3 n20(I'crud 2 ,100') Submit this GW-I within 30 days of well completion per the following:
20.09 24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing: (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
I/it wer lei e/is above casing,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.c.auger,roiap,,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,CCPCLJA
Penn it Program, 1611 MSC,Raleigh,NC 27699-16 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: .Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources; Revised 6-6-2018
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