WI0400551_Other_20210127

EOLOGIC
UEPLORATION
Environmental • Geotedmical
Specialty Drilling
January 19, 2021
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
RE: GW-1 Well Construction Record
Duke Energy
Belews Creek Steam Station
3195 Pine Hall Road
Belews Creek, NC 27009
To Whom It May Concern:
RECEIVED
JAlt 27 2021
i'q±:t DEQ/D
Central Office
Enclosed for your use is the GW-1 Well Construction Record for wells (IW-28, IW-30, IW-31, IW-33, IW-
38, IW-39, IW-44,1W-45, 1W-48, IW-51, IW-53, IW-54, IW-59, IW-62, IW-63, IW-65, IW-67, IW-69, IW-70,
IW-71). If you have any questions or require additional information, please do not hesitate to call me at
704-872-7686.
Sincerely,
Steve Taylor
176 Commerce Boulevard • Statesville, NC 28625 • Tel [phone] • [phone] • www. geologicexploration.com

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
BRIAN THOMAS
RECEIVED
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
JAN 2 7 202
NC DEQ/DW,
Central Office
2. Well Construction Permit #:
Lis/ all applicable well construction permits (i.e. County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipal/Public
Residential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring
Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
0 Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 11/16/20
5a. Well Location:
BELEWS CREEK STEAM STATION
Facility/Owner Name
©Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well ID#
IW-28
Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36° 17' 31.79"
80° 03' 50.88"
w
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or DM
If this is a repair, fill out known well construction information and explain the nature of the
repair under ii21 rentarks section or on the back of this 'brut.
S. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the .same construction, you can
.submit one jhrm.
9. Total well depth below land surface:
168.0
For multiple wells list all depths ifdijferen! (example- 3@200' and 2 a I00')
10. Static water level below top of casing: 31 '0 (ft.)
II -water level is above casing, use ' +
II. Borehole diameter: 6.0/12.0 (in.)
(ft.)
12. Well construction method: AIR
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
' ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
1 ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft'
148.0 ft•
6.0 in.
SCH 80
PVC
ft. ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
148.0 ft•
168.0 ft•
6.0 in.
.020
SCH 80
SS
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0 ft'
20.0 ft'
PORTLANDBENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft•
172.0 ft'
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION I color, hardness, ant/rack type, gain sine, etr.i
0.0 ft'
16.0 ft.
TAN SILTY SAND
16.0 ft•
23.0 ft
BROWN SILTY SAND
23.0 ft.
35.0 ft.
PWR
35.0 ft•
172.0 ft,
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:
Signature of Certified Well Contractor
12/15/20
Date
By signing this form, I hereby certify that the wells) was (were) constructed in accordance
with 15A NCAC 02C .0100 or /SA NCAC 02C .0200 Well Construction Standards. and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunpls & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-I
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc)
3. Well Use (check well use):
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells] OR LINER (if ap licable)
THICKNESS MATERIAL
FROM
ft.
TO
ft.
DIAMETER
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0
ft.
149.0 ft.
6.0
in.
SCH 80
PVC
ft.
ft.
in.
17. SCREEN
Water Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ lndustrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
❑ Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
ZGroundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
❑ Other (explain under #21 Remarks)
4. Date Well(s) Completed: 11/18/20 Well ID#
5a. Well Location:
BELEWS CREEK STEAM STATION
IW-30
Facility/Owner Name Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
149.0 ft.
169.0 ft.
6.0 in.
.020
SCH 80
SS
ft.
ft.
in.
19. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0 ft.
20.0 ft.
PORTLAND BENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable}
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft.
174.0 ft.
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG (+Hach additional wheels if necessary)
FROM
0.0 ft.
TO
16.0 ft.
D ISC ItIP1 ION I color, hardness, soil/rock pe, ,rain size, etc.1
TAN SILTY SAND
16.0 ft.
21.0 ft.
BROWN SILTY SAND
21.0 ft.
34.0 ft.
PWR
34.0 ft•
174.0 fr.
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36° 17' 31.79u N 80° 03' 50.88"
6. Is (are) the well(s): ZPermanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or ONo
If this is a repair, Jill out known well construction inf rrntation and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the sane construction, you can
submit one jam.
9. Total well depth below land surface: 169'0 (ft.)
For multiple wells list all depths iJ'dijferent (example- 3 a 200' and 2@l00')
10. Static water level below top of casing: 31.0 (ft.)
If water level is above casing, use ", "
I1. Borehole diameter: 6.0/12.0 on.)
12. Well construction method: AIR
(i.e. auger, rotary, cable, direct push, etc.)
-FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
22. Certification: �����+
12/15/20
Signature of Certified Well Contractor Date
By .signing this form, 1 hereby certify that the we//(s) was (mere) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form G W-1
North Carolina Department of Environment an
d Natural Resources - Division of Water Quality Revised Jan. 2013

WELL CONSTRUCTION RECORD (GW-11
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit #: WI0400551 /WV0400056
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Wells> 100,000 GPD
Non -Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑Geothemtal (Heating/Cooling Retum)
L9Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 11/18/20 Well ID# IW-31
5a. Well Location:
BELEWS CREEK STEAM STATION
Facility/Owner Name Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36° 17' 31.79° N 80° 03' 50.88°
6. Is(are) the well(s): ElPermanent or ❑Temporary
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (Wan licable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft'
147.0 it
6.0 'n•
SCH 80
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
147.0 ft.
167.0 It.
6.0 in'
.020
SCH 80
SS
ft.
ft.
in.
~18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0 ft.
20.0 ft.
PORTLAND BENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft.
172.0 ft.
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DFSCRWTI ON (tuln r. hardness, sonlreck type, Frain size, etc)
0.0 it
17.0 It.
TAN SILTY SAND
17.0 ft.
21.0 ft.
BROWN SILTY SAND
21.0 ft.
26.0 ft.
PWR
26.0 ft•
172.0 ft
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:
W
7. Is this a repair to an existing well: ❑Yes or IENo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 167.0 (ft.)
For multiple wells list all depths ifdi(lerent (example- 3@200' and 2@I00)
10. Static water level below top of casing: 31 .0 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 6.0/12.0 on.)
12. Well construction method: AIR
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _ Method of test:
13b. Disinfection type: Amount:
Signature of Certified Well Contractor
12/31/2020
Date
By signing this form, 1 hereby certO, that the well(s) eras (were) constructed in accordance with
15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a copy
of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supltlt and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit#:
List all applicable well construction permits (i.e. County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ lndustrial/Commercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
DMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
1Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 11/18/20 Well ID#
5a. Well Location:
BELEWS CREEK STEAM STATION
IW-33
Facility/Owner Name Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
County Parcel identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36° 17' 31.79" N 80° 03' 50.88"
6. Is (are) the well(s): ©Permanent or ❑Temporary
w
7. is this a repair to an existing well: DYes or ENo
/£this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection or non -water supply webs ONLY with the same construction, you can
submit one farm.
9. Total well depth below land surface:
For multiple wells list all depths ifdillerent (example- 3@200' and 2@I00')
10. Static water level below top of casing: 31.0
If water level is above casing, use "+- "
6.0/12.0 (in.)
12. Well construction method: AIR
169.0
1 1. Borehole diameter:
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if appllicable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft'
149.0 ft•
6.0 in.
SCH 80
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
149.0 ft
169.0 ft
6.0 in.
.020
SCH 80
SS
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0 ft.
20.0 ft.
PORTLANDBENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft
174.0 ft
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock h.pe, grain siu, etc.,
0.0 ft•
17.0 ft•
TAN SILTY SAND
17.0 ft
24.0 ft•
BROWN SILTY SAND
24.0 ft.
38.0 ft.
PWR
38.0 ft
174.0 ft'
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:
12/15/20
Signature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with I5A NCAC 02C .0100 or I5A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form G W-t North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit #: WI0400551 /WV0400056
List all applicable well construction permits (i.e. UIC, County, Stale, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Wells > 100,000 GPD
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap tlicablel
THICKNESS MATERIAL
FROM
ft.
TO
ft.
DIAMETER
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft
-
145.0 It.
6.0
in.
SCH 80
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
145.0 fr.
165.0 ft•
6.0 in.
.020
SCH 80
SS
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
Non -Water Supply Well:
Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
)Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 1 2/22/20 Well ID# IW-38
5a. Well Location:
BELEWS CREEK STEAM STATION
Facility/Owner Name Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
36° 17' 31.79° N 80° 03' 50.88"
6. Is(are) the well(s): MPermanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or MNo
I/'this is a repair, fill out known well construction information and explain the nature of the
repair under 421 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
165.0
9. Total well depth below land surface: (ft.)
For multiple wells list all depths ifdifferem (example- 3@200' and 2 rt 100')
10. Static water level below top of casing: 31.0 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 6-0/12.0 (in.)
12. Well construction method: AIR
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
2.0 ft.
20.0 ft•
PORTLAND BENTONITE
SLURRY
ft.
ft
ft.
ft.
19. SAND/GRAVEL PACK Cif applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft.
170.0 ft.
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG attach additional sheets if necessary)
FROM
0.0 ft-
TO
17.0 ft.
DESCRIPTION (color, hardness, soil/rock erpe, grain size, etc.)
TAN SILTY SAND
17.0 ft.
21.0 ft.
BROWN SILTY SAND
21.0 ft.
32.0 ft'
PWR
32.0 ft•
170.0 ft.
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:
12/31/2020
Signature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance with
15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a copy
of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Suppy and Open -Loop Geothermal Return Wells: Copy to the
county environmental fiealth department of the county where installed
24d. For Water Wells producing; over 100.000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
Form GW-t
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018

10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter: 6.0/12.0 (in.)
12. Well construction method: - AIR
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit #: WI0400551 /WV0400056
List all applicable well construction permits (i.e. UIC, County, Slate, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑ Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Wel Is > 100,000 GPD
Non -Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
DAquifer Storage and Recovery
❑ Aquifer Test
DExperimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
LE Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12/23/20 Well ID# IW-39
5a. Well Location:
BELEWS CREEK STEAM STATION
Facility/Owner Name
Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36° 17' 31.79" N 80° 03' 50.88"
6. Is(are) the well(s): EPermanent or ❑Temporary
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap Ilicable)
FROM _
1 TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft-
148.0 ft•
6.0 i"•
SCH 80
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
148.0 ft•
168.0 ft•
6.0 in'
.020
SCH 80
SS
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0 ft-
20.0 ft-
PORTLANDBENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft•
173.0 ft.
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING
1.00 (attach additional sheets if necessary)
FROM
-ro
DESCRIPTION (color, hardness, soit/rock type, grain size, etc.)
0.0 ft.
14.0 ft.
TAN SILTY SAND
14.0 It
21.0 It.
BROWN SILTY SAND
21.0 ft.
33.0 ft.
PWR
33.0 ft•
173.0 ft.
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:
W
7. is this a repair to an existing well: ❑Yes or ElNo
(Phis is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3@200' 200' and 2@100')
31.0
168.0
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
7GLs.. V ur--
12/31 /2020
Signature of Certified Well Contractor Date
By signing this form, !hereby certify that the well(s) was (were) constructed in accordance with
15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a copy
()Phis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100.000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit #: WI0400551 /WV0400056
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Wells > 100,000 GPD
Non -Water Supply Well:
['Monitoring ['Recovery
Injection Well:
['Aquifer Recharge
['Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
❑Geothermal(Closed Loop)
❑Geothermal (Heating/Cooling Return)
Groundwater Remediation
['Salinity Barrier
❑Stormwater Drainage
['Subsidence Control
['Tracer
['Other (explain under #21 Remarks)
4. Date Well(s) Completed: 1 2/28/20 Well ID#
5a. Well Location:
BELEWS CREEK STEAM STATION
IW-44
Facility/Owner Name Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36° 17' 31.79" ,, 80° 03' 50.88"
6. Is(are) the well(s): &Permanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or ONo
If tills is a repair, fill out known well construction information and explain the nature of the
repair under #2I remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 165.0 (ft.)
For multiple wells list all depths if different (example- 3 a 200' and 2@100)
10. Static water level below top of casing: 31 •0 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 6.0/12.0 (in.)
12. Well construction method: AIR
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells( OR LINER (if an licablel
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft•
145.0 ft•
6.0 '"•
SCH 80
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
145.0 ft'
165.0 ft•
6.0 '"'
.020
SCH 80
SS
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD& AMOUNT
2.0 ft•
200 ft•
PORTLANDBENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK fir applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft.
170.0 ft•
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING
LOG {attach additional sheets if necessary)
FROM
TO
I}RSCRIPTION I color, hardness,'oilimck type, grain size, ete.i
0.0 ft'
13.0 ft.
TAN SILTY SAND
13.0 ft.
18.0 ft.
BROWN SILTY SAND
18.0 ft.
32.0 ft•
PWR
32.0 ft-
170.0 ft•
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:Our-
1/13/2021
Signature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance with
15A NCAC 02C .0(00 or ISA NCAC 02C .0200 Well Construction Standards and that a copy
of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit #: WI0400551 /WV0400056
List all applicable trel construction permits (i.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Wells > 100,000 GPD
Non -Water Supply Well:
Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12/21 /20 Well ID# IW 45
5a. Well Location:
BELEWS CREEK STEAM STATION
Facility/Owner Name
Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36° 17' 31.79" N 80° 03' 50.88"
6. Is(are) the well(s): ElPermanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or l9No
I/'this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 168'0 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: 31 .0 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 6.0/12.0 (in.)
12. Well construction method: AIR
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if aplicablel
FROM
TO
DIAMETER
THICKNESS
J MATERIAL
ft.
ft.
in.
lJl
16. INNER CASING OR TUBING 'geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft
148.0 ft•
6.0 in'
SCH 80
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
148.0 it
168.0 ft.
6.0 in'
.020
SCH 80
SS
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0 ft.
20.0 ft.
PORTLAND BENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK{ if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft
173.0 ft.
20-40
FINE SILICA SAND
ft.
ft.
NI. DRILLING LOG (attach additiunal sheets if necessary)
FROM
TO
DESCRIPTION (valor. hardness, wRlrnr I. lyre, grain size, etc.I
0.0 ft'
17.0 ft'
TAN SILTY SAND
17.0 ft•
29.0 ft
BROWN SILTY SAND
29.0 ft.
39.0 ft'
PWR
39.0 ft.
173.0 ft
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:
Our-
12/31/2020
Signature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s) was (here) constructed in accordance with
15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a copy
of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing; over 100,000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
Fonn GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit#: WI0400551/WV0400056
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural
CI Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irritation
❑Municipal/Public
❑Residential Water Supply (single)
❑ Residential Water Supply (shared)
❑ Wells > 100,000 GPD
Non -Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
O Groundwater Remediation
❑ Sal inity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑ Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12/29/20 Well ID# IW-48
5a. Well Location:
BELEWS CREEK STEAM STATION
Facility/Owner Name Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36° 17' 31.79" N 80° 03' 50.88"
6. Is(are) the well(s): OPermanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or ONo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 165.0 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: 31 .0 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 6-0/12.0 (in.)
12. Well construction method: AIR
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for
multi -cased wells) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS I MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TUBING (geothermal closed -loony
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft•
145.0 ft.
6.0 in•
SCH 80
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
145.0 ft
165.0 ft•
6.0 in'
.020
SCH 80
SS
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0 ft•
20.0 ft•
PORTLANDBENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL
PACK; if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft•
170.0 ft.
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG tanarh additional sheen; if necessary)
FROM
TO
DESCRIPTION /eelnr. uailium. soil/rock Type, K rain size, ete.l
0.0 ft•
13.0 ft•
TAN SILTY SAND
13.0 ft•
20.0 ft•
BROWN SILTY SAND
20.0 ft.
33.0 ft.
PWR
33.0 ft•
170.0 ft•
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:
Signature of Certified Well Contractor
1/13/2021
Date
By signing this form, I hereby certify that the wells) was (were) constructed in accordance with
15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a copy
of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where instld
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
Fonn GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit #: WI04005 51 /WV0400056
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Wells > 100,000 GPD
Non -Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
Groundwater Remediation
❑ Sal inity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
IW-51
4. Date Well(s) Completed: 1 2/30/20 Well ID#
5a. Well Location:
BELEWS CREEK STEAM STATION
Facility/Owner Name Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36° 17' 31.79" N 80° 03' 50.88"
6. Is(are) the well(s): (!Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or t! No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 164'0 _ (ft.)
For multiple wells list all depths ifdii ferent (example- 3@200' and 2@100')
10. Static water level below top of casing: 31'0 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 6.0/12.0 on.)
12. Well construction method: AIR
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap
licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft.
144.0 ft•
6.0 l'
SCH 80
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
144.0 It
164.0 ft.
6.0 in'
.020
SCH 80
SS
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0 ft-
20.0 ft.
PORTLANDBENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK( if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft.
169.0 ft.
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING 1.OG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color. ha rdoess, soii/ruck type, /rain size, etc.'
0.0 ft.
16.0 ft•
TAN SILTY SAND
16.0 ft.
23.0 ft.
BROWN SILTY SAND
23.0 ft'
36.0 ft.
PWR
36.0 ft•
169.0 ft•
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:
1/13/2021
Signature of Certified Well Contractor Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance with
1SA NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a copy
of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Infection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Suppy and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft. 1 ft.
15. OUTER CASING (for multi -cased wells) OR LINER 1if ap Iicahie)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑ Irrigat ion
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
0 Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
©Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
0 Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12/09/20 well ID# IW-53
5a. Well Location:
BELEWS CREEK STEAM STATION
Facility/Owner Name Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS 1 MATERIAL
0.0 ft.
120.0 ft•
6.0
in.
SCH 80
PVC
130.0 ft.
150.0 ft.
6.0
in.
SCH 80
PVC
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
120.0 ft.
130.0 ft.
6.0 in.
.020
SCH 80
SS
150.0 ft.
170.0 ft• 6.0 in.
.020
SCH 80
SS
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0 ft.
20.0 ft.
PORTLAND BENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft•
175.0 ft.
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
0.0 ft.
TO
17.0 ft.
DF.SCRIPT/ON {color, hardness, soil/rock t jc, grain size, etc.l
TAN SILTY SAND
17.0 ft.
24.0 ft.
BROWN SILTY SAND
24.0 ft.
37.0 ft.
PWR
37.0 ft•
175.0 ft.
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL -- 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36° 17' 31.79° N 80° 03' 50.88°
W
6. is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 170•0 (ft.)
For multiple wells list all depths ifdii different (example- 3@200' and 2@l00')
10. Static water level below top of casing: 31.0 (ft.)
If water level is above casing, use '•+ ••
11. Borehole diameter: - 6.0/12.0 (in.)
12. Well construction method: AIR
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
22. Certification: /^
12/15/20
Signature of Certified Well Contractor Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with I5A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013

WELL CONSTRUCTION RECORD ( GW-1)
For Internal Use Only:
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit #: WI0400551 /WV0400056
List all applicable well construction permits (i.e. UIC, County, Stale, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
El Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑ Irrigation
❑Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Wells > 100,000 GPD
Non -Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
INGroundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑ Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12/31/20 Well ID# IW-54
5a. Well Location:
BELEWS CREEK STEAM STATION
Facility/Owner Name Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36° 17' 31.79" N 80° 03' 50.88"
6. Is(are) the well(s): IEPermanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or IJNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 164.0 (ft.)
For multiple wells list all depths ifdifferent (example- 3 t[✓r 200' and 2 t)100')
10. Static water level below top of casing: 31.0 (ft.)
If lemur level is above casing, use "+"
11. Borehole diameter: 6.0/12.0 on.)
12. Well construction method: AIR
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _ Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER of ap licablel
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft•
144.0 ft-
6.0 in'
SCH 80
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
144.0 ft•
164.0 ft.
6.0 in'
.020
SCH 80
SS
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0 ft.
200 ft.
PORTLANDBENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK ( if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft.
168.0 ft.
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING
LOG [attach additional sheets if necessar'}
FROM
TO
DESCRIPTION Kolar, haiiIness. seilhrnck type, gain size, etc.)
0.0 ft'
14.0 ft•
TAN SILTY SAND
14.0 ft.
24.0 ft•
BROWN SILTY SAND
24.0 ft•
37.0 ft'
PWR
37.0 ft•
168.0 ft*
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:
G-
Signature of Certified Well Contractor
1/13/2021
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance with
15A NCAC 02C .0100 or I5A NCAC 02C .0200 Well Construction Standards and that a copy
of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100.000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit #: WI04005 51 /WV0400056
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑ Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Wells> 100,000 GPD
Non -Water Supply Well:
❑Monitoring ❑ Recovery
Injection Well:
❑ Aquifer Recharge
DAquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
(Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 01 /07/21 Well ID#
5a. Well Location:
BELEWS CREEK STEAM STATION
IW-59
Facility/Owner Name Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Ialllong is sufficient)
36° 17' 31.79" N 80° 03' 50.88"
6. Is(are) the well(s): I!JPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ElNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 166.(ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: 31 '0 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 6-0/12.0 (in.)
12. Well construction method: AIR
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
' ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft.
146.0 ft
6.0 in'
SCH 80
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
146.0 ft
166.0 ft'
6.0 in'
.020
SCH 80
SS
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0 ft•
20.0 ft.
PORTLANDBENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft.
170.0 ft.
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary) '
FROM
TO
DESCRIPTION [rola r. Intrdaeas, saitlruck eype, train sire. etc.]
0.0 ft.
13.0 ft
TAN SILTY SAND
13.0 it.
22.0 ft.
BROWN SILTY SAND
22.0 ft'
34.0 ft.
PWR
34.0 ft.
170.0 ft.
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL ' 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:
1 /13/2021
Signature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s) was (were,) constructed in accordance with
15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a copy
of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producine over 100,000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 6-6-2018

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
DAquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
OGroundwater Remediation
❑ Sal inky Barrier
❑Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12/03/20 Well ID#
5a. Well Location:
BELEWS CREEK STEAM STATION
IW-62
Facility/Owner Name Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36° 17' 31.79" N 80° 03' 50.88°
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
If this is a repair, Jill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
S. Number of wells constructed: 1
For multiple injection or non -water. supply wells ONLY with the same construction, you can
.submit one form.
9. Total well depth below land surface: 165.0 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2©100')
10. Static water level below top of casing: 31.0 (ft.)
Ifwater level is above casing, use "+"
11. Borehole diameter: 6.0/12.0 (in.)
12. Well construction method: AIR
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER
CASING (for
multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
L
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft
145.0 ft'
6.0 in.
SCH 80
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
145.0 ft'
165.0 ft
6.0 in.
.020
SCH 80
SS
ft.
ft.
in.
1S. GROUT
FROM
TO
MATERIAL
EMPLACEM ENT METH OD&AMOUNT
2.0 ft'
20.0 ft.
PORTLANDBENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft
170.0 ft'
20-40
FINE SILICA SAND
ft.
ft.
20, DRILLING LOG (attach additional sheets if necessary]
FROM
TO
DESCR I P"I'10\{color, hardness, sod/rack hpe, vain size, etc.)
0.0 ft•
12.0 ft
TAN SILTY SAND
12.0 ft•
23.0 ft.
BROWN SILTY SAND
23.0 ft
36.0 et'
PWR
36.0 ft
170.0 ft•
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:
12/15/20
Signature of Certified Well Contractor Date
By signing this form, I hereby certify that the wel(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or I5A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013

10. Static water level below top of casing:
If water level is above casing, use "+"
H. Borehole diameter: 6.0/12.0 (in.)
AIR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irritation
❑ Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return]
4. Date Well(s) Completed: 12/02/20
5a. Well Location:
BELEWS CREEK STEAM STATION
Facility/Owner Name
JGroundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well ID#
IW-63
Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36° 17' 31.79" N 80° 03' 50.88n
w
6. Is (are) the well(s): 12Permanent or ❑Temporary
7. is this a repair to an existing well: ❑Yes or ONo
If this is a repair, Jill out known well construction information and explain the nature oldie
repair under ii2l remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the saute construction, you can
submit one firm.
9. Total well depth below land surface: 165.(ft.)
Far multiple wells list all depths if d Jferent (example- 3@200' 200' and 2 rt 100)
31.0
12. Well construction method:
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
[, FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -eased wells) OR LINER of all licablei
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed-loopl
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft'
145.0 ft
6.0 'n'
SCH 80
PVC
ft.
ft.
in.
17.SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
145.0 ft
165.0 ft
6.0 in'
.020
SCH 80
SS
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0 ft.
20.0 ft'
PORTLANDBENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACIt (if applicable(
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft
170.0 ft
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION I color, hardness, sod/rock h re, vain sire, etc.)
0.0 it
13.0 ft.
TAN SILTY SAND
13.0 ft
23.0 ft
BROWN SILTY SAND
23.0 ft
38.0 ft.
PWR
38.0 ft
170.0 ft
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:
Signature of Certified Well Contractor
12/15/20
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy aphis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-I
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (Le. County, State, Variance, etc.)
3. Well Use (check well use):
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licablel
FROM THICKNESS 1 MATERIAL
TO
ft.
ft.
DIAMETER
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft.
145.0 ft.
6.0
in.
SCH 80
PVC
ft.
ft.
in.
17. SCREEN
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑ Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
0 Monitoring
❑Recovery
Injection Well:
DAquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
©Groundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
❑ Geothermal (Heating/Cooling Return) ❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12/02/20 Well ID#
5a. Well Location:
BELEWS CREEK STEAM STATION
IW-65
Facility/Owner Name Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
Comity Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36° 17' 31.79" N 80° 03' 50.88"
W
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or 1No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
S. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 165.0 (ft.)
For multiple wells list all depths if diJerent (example- 3@200' 200' and 2 a l00')
10. Static water level below top of casing: 31.0 (ft.)
If water level is above casing, use ••+"
11. Borehole diameter: 6.0/12.0 on.)
AIR
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
145.0 ft.
165.0 ft.
6.0 in.
.020
SCH 80
SS
ft.
ft.
in.
1S. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0 ft.
20.0 ft.
PORTLAND BENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK if alrplicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft.
170.0 ft.
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG ialrach odditinnal sheets if necessaryL
TO
FROM
0.0 ft'
12.0 ft.
(DESCRIPTION (color, hardness, soil/rock ty e, grain size, etc.1
TAN SILTY SAND
12.0 ft
23.0 n•
BROWN SILTY SAND
23.0 ft.
38.0 ft•
PWR
38.0 ft
170.0 ft.
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:
Signature of Certified Well Contractor
12/15/20
Date
By signing this form, 1 hereby c'erti/y that the well(s) was (were) constructed in accordance
with 1 SA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Suipht & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-I
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit#:
List all applicable well construction permits 0.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Well:
❑ Monitoring
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 12/01/20
5a. Well Location:
BELEWS CREEK STEAM STATION
Facility/Owner Name
©Groundwater Remediation
❑ Sal inity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑Other (explain under #21 Remarks)
Well ID#
IW-67
Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
Co- unty
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36° 17' 31.79"
80° 03' 50.88"
6. Is (are) the well(s): (Permanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or ENo
If this is a repair, Jill out known well construction information and explain the nature of the
repair under i121 remarks section or on the back of this prin.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the sante construction, you can
submit one form.
9. Total well depth below land surface:
167.0
For multiple wells list all depths ifdferent (example- 3@200' and 2@100)
(ft.)
10. Static water level below top of casing: 31'0 (ft.)
if hater level is above casing, use "+"
11. Borehole diameter: 6.0/12.0 on.)
12. Well construction method: AIR
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap .licablel
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft'
147.0 ft'
6.0 in.
SCH 80
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
147.0 ft•
167.0 ft.
6.0 in'
.020
SCH 80
SS
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0 ft'
20.0 ft.
PORTLAND BENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft
173.0 it
20-40
FINE SILICA SAND
ft.
ft.
20. DRl LLI NG LOG I attach additional sheets if necessar rj
FROM
' TO
DESCRIPTION I color, hardness, soil/rock r� i,e, grain size, etc.)
0.0 ft.
22.0 ft.
TAN SILTY SAND
22.0 ft
30.0 ft.
BROWN SILTY SAND
30.0 ft.
41.0 ft.
PWR
41.0 ft.
173.0 ft•
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:
Signature of Certified Well Contractor
12/15/20
Date
By signing this Jbrm, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or /SA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑ Industrial/Commercial ❑Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge OGroundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑ Aquifer Test ❑Stormwater Drainage
❑ Experimental Technology ❑Subsidence Control
❑ Geothermal (Closed Loop) ❑Tracer
❑Geothermal (Heating/Cooling Return) ❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 11/25/20 Well ID# IW-69
5a. Well Location:
BELEWS CREEK STEAM STATION
Facility/Owner Name
Facility I D# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36° 17' 31.79" N 80° 03' 50.88"
6. Is (are) the well(s): OPermanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or DNo
/f this is a repair, fill out known well construction information and explain the nature of the
repair under.421 remarks section or on the back of this form.
S. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 1 70.0 (ft.)
For multiple wells list all depths ifdifferent (example- 3@200' and 2@100')
10. Static water level below top of casing: 31 '0 (ft.)
If water level is above casing, use "+"
II. Borehole diameter: 6.0/12.0 (in.)
12. Well construction method: AIR
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING I for multi -cased wells) OR LINER Of ap licablel
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft•
150.0 ft
6.0 in.
SCH 80
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
150.0 ft.
170.0 ft•
6.0 in'
.020
SCH 80
SS
ft.
ft.
in.
IS. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0 ft.
20.0 ft.
PORTLANDBENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK iif applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft.
175.0 ft•
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG {attach additional sheets if necessary)
FROM
TO
DESCRIPTION {color, hardness, soil/ rock tnre„grain size, etc./
0.0 ft•
25.0 ft.
TAN SILTY SAND
25.0 ft.
33.0 ft.
BROWN SILTY SAND
33.0 ft•
51.0 ft.
PWR
51.0 ft•
175.0 ft•
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL . 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:
Signature of Certified Well Contractor
12/15/20
Date
By signing this flirt:, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy ofthis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form G W - t
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells/ OR LINER /if ap livable)
FROM THICKNESS 1 MATERIAL
TO
ft.
ft.
DIAMETER
in.
16. INNER CASING OR TUBING (geothermal closed-loopt
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0
ft.
150.0 ft
6.0
in.
SCH 80
PVC
ft.
ft.
in.
17. SCREEN
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Com merc iat
❑ Irrigation
❑Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑ Monitoring
❑Recovery
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑ Experimental Technology
❑Geothermal(Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 11/24/20
5a. Well Location:
BELEWS CREEK STEAM STATION
©Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑ Other (explain under #21 Remarks)
Well ID#
IW-70
Facility/Owner Name Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36° 17' 31.79" N 80° 03' 50.88"
w
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
Ifihis is a repair, Jill out known well construction information and explain the nature ofthe
repair under #21 remarks section or on the back of this, form.
8. Number of wells constructed: 1
For multiple in/eclion or non -water supply wells ONLY with the same construction, you can
submit one form.
170.0
9. Total well depth below land surface: (ft.)
For multiple wells list all depths ifderenl (example- 3@200' and 2@100')
10. Static water level below top of casing: 31.0 (ft.)
lfwater level is above casing, use "+"
11. Borehole diameter: 6.0/12.0 (in.)
12. Well construction method:
AIR
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
150.0 ft.
170.0 ft.
6.0 in. ,
.020
SCH 80
SS
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0 ft.
20.0 ft.
PORTLAND BENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft-
175.0 ft
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
0.0 ft.
TO
28.0 ft
DESCRIPTION [color, hardness, soil/rock npe, grain size, etc.)
TAN SILTY SAND
28.0 ft
37.0 ft.
BROWN SILTY SAND
37.0 fr.
68.0 ft.
PWR
68.0 ft
175.0 ft.
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification: _(
Signature of Certified Well Contractor
12/15/20
Date
By signing this form, I hereby cert( that the ive/(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or I5A NCAC 02C .0200 Well Construction Standards and that a
copy alibis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL 1NSTUCT1ONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunnly & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form CiW-I
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑ Irrieation
❑ Municipal/Public
:Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑Recovery
©Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑Geothermal (Heating/Cooling Return) ❑Other (explain under #2I Remarks)
4. Date Well(s) Completed: 11/23/20 Well ID#
5a. Well Location:
BELEWS CREEK STEAM STATION
IW-71
Facility/Owner Name Facility ID# (if applicable)
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address, City, and Zip
STOKES
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
36° 17' 31.79" N
80° 03' 50.88"
W
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ENo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the sante construction, you can
submit one form.
9. Total well depth below land surface: 168'0 (ft.)
For multiple wells list all depths ifdi„(ferent (example- 3@,200' and 2@100)
10. Static water level below top of casing: 31 '0 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 6.0/12.0 on.)
12. Well construction method: AIR
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
FROM Y
TO Yy
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING for multi -cased wells) OR LINER (if ap licable)
THICKNESS PI MATERIAL
FROM TO
ft.
ft.
DIAMETER
in.
16. INNER CASING OR TUBING (geothermal closed -loom
FROM TO
DIAMETER
THICKNESS
MATERIAL
0.0 fr.
73.0 ft.
63.0 ft'
148.0 ft.
6.0
6.0
in.
in.
SCH 80
SCH 80
PVC
PVC
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
63.0 ft'
73.0 ft.
6.0 in.
.020
SCH 80
SS
148.0 ft.
168.0 ft.
6.0 in.
.020
SCH 80
SS
l8. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0
It.
20.0
ft.
PORTLANDBENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft.
183.0 ft•
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG lautarh addilionul aher ls if
FROM
10
II t'SCRI PTION Voter. ha Mons. soiFrnck type. grain size, etc.]
0.0
ft'
27.0
ft•
TAN SILTY SAND
27.0
ft•
36.0
ft.
BROWN SILTY SAND
36.0
ft.
68.0
ft.
PWR
68.0
ft.
183.0
ft
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:
12/15/20
Signature of Certified Well Contractor Date
By signing this form, I hereby certify that the wells) was (were) constructed in accordance
with 15A NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013