GW1-2022-10682_Well Construction - GW1_20221205

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: !
I.Well Contractor Information:
BRIAN THOMAS ,:* 14.WATER ZONES
Well.Contractor Name �:.' `�,yi�,d, f
q,,,,&.-_�✓ FROM TO' DESCRIPTION
A - 2581 2022 NC Well Contractor Certification Number �+ ,tom; 15.OUTER CASING for multi-cased wells OR-LINER ifa Iicable)
GEOLOGIC EXPLORATION "�"
r..-- -f;;?""1 r ri•,,.;�.,��+•' FROM TO DIAMETER, THICKNESS MATERIAL
ft. ft. in.
Company Narne +-"`
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
Liao all applicable well construction permits(i.e.U1C.County State,Variance,etc.) 0.0 rt• 135.0 rt' 6.0 in. SCH 40 PVC
3.Well Use(check well use): it. ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 135.0 ft' 155.0 ft' 6.0 1n. .010 SCH 40 PVC
❑Geothermal(Fleating/Cooling Supply) ❑Residential Water Supply(single) in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wel Is> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft,
20.0 rt. AQUA GUARD SLURRY
MMonitoring ❑Recovery fr. fr.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa Iicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stortnwater Drainage 25.0 rt• 160.0 rt• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. I .
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION color,hardness,soillrock type, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 rt• 18.0 ft- BROWN SILTY SAND
4.Date Well(s)Completed: 1 O/26/22 Well ID# EX-82 18.0 ft. 38.0 ft. TAN SILTY SAND
ia.Well Location: 38.0 ft' 74.0 ft' PWR
BELEWS CREEK STEAM STATION 74.0 ft. 160.0 ft. ROCK
Facility/Owner Name Facility ID#(ifapplicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address,City,and Zip ft. ft.
STOKES 21.RENIARKS'. .
County Parcel Identification No.(PIN)
BENTONITE SEAL-20.0-25.0 FEET
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
SUMP- 1 S5.0- 156.0 FEET
(if well field,one Iat/long is sufficient) 22.Certification:
929334.86 N 1682610.64 W �j1kr
10/31/22
6.Is(are)the well(s): l+EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)earsvacied in accordance with
7.Is this a repair to an existing well: ❑Yes or IENo l.iA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standardv and that a copy
ljthi.s is a repair,fill out known well construction ht/brntation and explain the native ofdhe ofthis record has been provided to the well owner
repair antler S11 remarks section or on the back of this•fbrn.
23.Site diagram or additional well details:
S.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-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: 155.0 (ft.)
For multiple wells list all depths ifdiJj rent(example-3 rt 200'and?a@1100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 59.05 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
!f tracer level is nbm•e caring,use"+"
htformation Processing Unit. 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 10.0 (in) 24b. For Injection Wells: Copy tO;DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
AIR 1
12.Well construction method: 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
FOR WATER SUPPLY YELLS ONLY: 24d.For Water Wells producing over.100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 114ethod of test:
Penn it Program,1611 MSC,Raleigh NC 27699-1611
13b.Disinfection type: Amount: i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018