GW1-2022-01391_Well Construction - GW1_20220124

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES k i
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 2581 ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased`wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft 40.0 ft 6.0 i" SCH 40 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) 0.0 ft- 95.0 fl' 2.0 t"' SCH 40 PVC
3.Well Use(check well use): fr. fr. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 95.0 ft. 105.0 it' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 48.0 ft- AQUA GUARD SLURRY
OflMonitoring ❑Recovery 0.0 ft- 40.0 ft' PORTLANDBENTONITE SLURRY
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 89.0 it1 111.0 rt• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING.LOC attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilhrock type,prain size,etc.
0.0 it 9.0 It. BROWN SILTY SAND
4.Date Well(s)Completed: 10/04/21 well ID# CP-6BRL 90 ft- 18.0 ft- DARK BROWN SILTY SAND
5a.Well Location: 18.0 ft' 27.0 ff I ",`;PWR' 4
BELEWS CREEK STEAM STATION 27.0 ft 111.0 ft ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address,City,and Zip ft. ft. ,
STOKES 21.REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL-48.0-89.0 FEET
***U-PACK SCREEN***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one hat/long is sufficient) 22.Certification:
360 28' 10.13" N 800 06' 30.58" W !:2srcl 611-
11/22/21
6.Is(are)the well(s): INPermanent or ❑Temporary Signatwe of Certified Well Contractor Date
By signing Plus form,/hereby certify that the wells)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!9No 1 JA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
U this is"repair,fill out known well construction hitbritunion and explain the nature of the gl'this record has been prorided to the well owner.
repair under tt21 remarks section or on the back gfthis 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 necessan'.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 105.0 (ft.)
h'or mulliple wells list all depths i/'different(exmnple-3@a 100'and 2 t@r l00') Submit this GW-1 within 30 days of well completion per the following:
12.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
]0.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f water level is above casing,use"+"
6.0/10.0 24b. For Infection Wells: Copy to�DWR,Underground Injection Control(IUC)
11.Borehole diameter: AIR (In) Program, 1636 MSC,Raleigh,NC 24 699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing Iver 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
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Fonn G W-I North Carolina Department of Environmental Quality-Division of Water Resources( Revised 6-6-2018
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