WI0400551_Other_20201220

EOLOGIC
EPLORATION
Environmental • Geotechnical
Specialty Drilling
December 14, 2020
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
DEC 21 2020
NC DEQ/DWR
Central Office
Enclosed for your use is the GW-1 Well Construction Record for wells (IW-68, IW-72). If you have any
questions or require additional information, please do not hesitate to call me at 704-872-7686.
Sincerely,
,o&-Jr
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
For Internal Use ONLY:
1. Well Contractor Information:
BRIAN THOMAS
Well Contractor Name
A - 2581
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
RECEIVED
DEC 212020
Company Name
DECIIMIR
2. Well Construction Permit #: r.entral Mee
List all applicable well construction permits (i.e. County, Slate, Varianb4, 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)
©Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 10/19/20 Well ID# IW-72
5a. Well Location:
BELEWS CREEK STEAM STATION
Facility/Owner Name Facility 1D# (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' 31.79u 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 11No
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 same construction, you can
submit one form.
9. Total well depth below land surface: 175'0 (ft.)
For multiple wells list all depths ifdifferent (example- 3 «200' and 21Q100')
10. Static water level below top of casing: 35.(ft.)
limner 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:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING ifor multi -cased wells) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft.
55.0 ft.
6.0 in.
SCH 80
PVC
65.0 ft.
155.0 ft.
6.0 in.
SCH 80
PVC
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
55.0 ft.
65.0 ft.
6.0 in.
.020
SCH 80
SS
155.0 ft175.0
ft•
6.0 in*
.020
SCH 80
SS
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2.0 ft.
200 ft.
PORTLANDBENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL
PACK
of applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.0 ft.
iao.o ft.
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary.)
FROM
TO
DESCRIPTION I color, hardness, soil/rock lyre, erain size, etc.(
0.0 ft•
15.0 ft
TAN SILTY SAND
15.0 ft.
57.0 ft
BROWN SILTY SAND
57.0 ft.
65.0 ft.
PWR
65.0 ft•
180.0 ft'
ROCK
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 20.0 - 30.0 FT (WIRE WRAPPED SCREEN)
22. Certification:
10/23/20
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 wel! 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
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 q 9q rm2®
Company Name ®EC 61 F (.,1
2. Well Construction Permit #: \I t
List all applicable well construction permits (i.e. Countx,r,4twtf�eiay
3. Well Use (check well use): VOeCtI(a a+�+
Water Supply Well:
❑Agricultural
EGeothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
❑ Monitoring
❑ Municipal/Public
❑ Residential Water Supply (single)
DResidential Water Supply (shared)
❑Recovery
Injection Well:
❑ Aquifer Recharge
:Aquifer Storage and Recovery
❑ Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
10/15/20
4. Date Well(s) Completed:
5a. Well Location:
BELEWS CREEK STEAM STATION
©Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑ Subsidence Control
❑Tracer
❑Other (explain under #2 l Remarks)
Well ID# IW-68
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`repuir to an existing well: ❑Yes or ONo
If this is a repair, fill oul 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 same construction, you can
submit one form.
9. Total well depth below land surface: 167'0 (ft.)
For multiple wells list all depths ifdifferent (example- 3@a 200' and 2 a 100')
10. Static water level below top of casing: 34'0 (ft.)
if water level is above casing, use "+"
11. Borehole diameter: 6.0/12A (in.)
12. Well construction method: AIR
(i.eauger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
136. 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'
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.
ft'
20.0
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
DtSCRIPI ION icolor,hardness, soi Frock r.pe, grain size., etc.I
0.0 ft•
16.0 ft.
TAN SILTY SAND
16.0 ft.
58.0 ft.
BROWN SILTY SAND
58.0 ft
66.0 ft.
PWR
66.0 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
10/23/20
Date
By signing this farm, l 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 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