GW1-2022-10679_Well Construction - GW1_20221205

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: '
BRIAN THOMAS 14.WATER ZONES
Well Contractor Name __ t, ��, FROM ft TO DESCRIPTION
ft.
A - 2581 °t ;;
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for lti-caseMETd wells OR LINER if a licable mu TE
GEOLOGIC EXPLORATION Dr ,i ���� FROM TO DIAER TH ICK rNESS MARIAL
_ _ ft. ft. in.
Company Name 1{htidS:;��;,_a fat:<.,.='�.,a>>.,,J
,r,;Ap Q;: OG 16.INNER CASING OR TLiBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
list all applicable well construclion pertnits(i.e.U/C.Cou n(F,State,Varlance,etc.) 0.0 ft. 140.0 ft- 6.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 140.0 fr' 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
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Wcll: 0.0 ft• 20.0 ft• AQUA GUARD SLURRY
25Monitoritig ORecovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 25.0 fry 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#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/mck type,grain size,etc.
0.0 ft• 7.0 ft- BROWN SILTY SAND
4.Date Well(s)Completed: 10/28/22 Well ID# EX-78 7.0 ft- 23.5 ft- TAN SILTY SAND
Sa.Well Location: 23.5 ft- 81.0 ft. PWR
BELEWS CREEK STEAM STATION 81.0 ft. 165.0 ft. ROCK
Facility/Owner Name Facility ID#(irapplicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 fry rt.
Physical Address,City,and Zip
ft. ft.
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-20.0-25.0 FEET
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees: SUMP- 160.0- 161.0 FEET
(if well field,one lat/long is sufficient) 22.Certification:
929268.82 N 1682426.43 W f altz., 6vw--
10/31/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
Hy signing Ibis Jbrnn,/hereby ceriifyy that the ire//(s)Bras(mere)constructed in accordance milk
7.Is this a repair to an existing well: ❑Yes or 25No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Conslruclion Standards and that a cons
Il'this is a repair,fill not known well construclion itrforntation and erplain the nature of the of this reca•c/has been prorided to the well owner.
repair under•r?l remarks section or on the back aJ7hisJbrm.
23.Site diagram or additional well details:
S.For Gcoprobe/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-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: 160.0 (ft.)
For inulliple weus fist al/depth.,iJ'd/Jfereul(exannple-3 200'and? 100') Submit this GW-I within 30 days of well completion per the following:
56.16 24a. For All Wells: Original form to Division of Water Resources (DWR),
Static water level below top of casing: (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
1f/'u nler level is above cnriuy,use„+..
10.0 24b. For Injection Wells: Copy toIDWR,Underground Injection Control(lUC)
I I.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,rohiry,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
Permit Program, 1611 MSC,Raleigh',NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2015