GW1-2022-01390_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
Well Contractor Name FROM TO ft.
A - 2581 DESCRIPTION
ft.
ft. 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
0.0 It• 86.0 ft• 6.0 in- SCH 40 PVC
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.111C,Count),,State,Variance,etc.) 0.0 IL 137.0 ft. 2.0 !. in. SCH 40 PVC
3.Well Use(check well use): 0.0 It• 114.0 ft. 4.0 in. SCH 40 PVC
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 133.0 ft' 143.0 ft' 2.0 "-' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It- 93.0 It• AQUA GUARD SLURRY
TIMonitoring ❑Recovery 0.0 ft- 86.0 It. PORTLANDBENTONrrE SLURRY
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 0.0 ft- 114.0 It' PORTLANDBENTONRE SLURRY
99.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 127.0 ft. 145.0 It• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
0.0 It• 12.0 It• BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 10/04/21 Well ID# CP-10BR 12.0 It• 33.0 It• BROWN SILTY SAND
5a.Well Location: 33.0 It. 58.0 ft• DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION 58.0 ft. 114.0 ft- PWR
Facility/Owner Name Facility ID#(if applicable) 114.0 ft- 145.0 It. R6CK -
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address,City,and Zip ft. ft. ` .,
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-93.0-127.0 FEET
***U-PACK SCREEN***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
360 28' 65.17" N 800 06' 42.00" W sn- --
11/22/21
6.Is(are)the well(s): [9Permanent or ❑Temporary Signature ofCertified Well Contractor Date
By.signing this form,1 hereby certify that the weIlls)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
I1'd is is a repair,fill out known well construction information and explain the nature of the of phis record has been provided to the well owner.
repair under 921 remarks section or on the back of this farm.
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 1 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: 143.0 (ft.)
por multiple wells list a//depths//'different(example-3 r@200'and 2@100') Submit this GW-I within 30 days of well completion per the following:
73.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if water level is above casing,use"+"
11.Borehole diameter:
6.0/10.0 (in.) 24b. For Infection Wells: Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR 1
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
i
13b.Disinfection type: Amount: II
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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