GW1-2022-01367_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 2581
rt. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.WCII COnStrUC110n Permit#: FROM TO DIAMETER THICKNESS MA A
TERIL
List all applicable well construction permits(1.e.UIC.County,State,Variance,etc) 0.0 ff• 43.0 ff• 1.0 i"' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 43.0 rL 53.0 f' 1.0 1O' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.'
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri at10n ❑Wclls> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 35.0 f' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery ft. rt.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 41.0 ft- 53.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. fr.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.
0.0 ft. 11.0 ft. BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 11/19/21 well ID# FGDLFPZ-25 11.0 ft- 280 ff• BROWN SILTY SAND
5a.Well Location: 28.0 ft' 31.0 ft' DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION 31.0 ft- 53.0 ft-
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. -
3195 PINE HALL ROAD BELEWS CREEK 27009 rt. ft. J AN v 4 2 022)
-
Physical Address,City,and Zip
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-35.0-41.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
360 27' 24.53" N 800 05' 61.05" W �a/ �-- 0.7- 12/10/21
6.Blare)the well(s)• OPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,1 hereby certify that the well(s)seas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the oJ7his record has been provided to the well owner.
repair under 1t21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 53.0 (ft.)
For multiple wel/s list all depths ifdiijfereni(example-3 r@i 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 43.5 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/fwarer level is above casing,use
11.Borehole diameter: 6.0 (in.) 24b. For Infection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR
24c.For Water Supply and Open'Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where Installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells nroduciyg over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-161 I
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources,! Revised 6-6-2018