GW1-2022-01397_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 p i.
Well Contractor Name FROM TO DESCRIPTION
A - 2581
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'weIts OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft• 52.0 ft- 6.0 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.U/C,County,State,Variance,etc) 0.0 ft- 74.0 ft. 2.0 in• SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 74.0 ft• 84.0 ft' 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) tr. R. in.'
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrl anon ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 rt• 62.0 ft- AQUA GUARD SLURRY
MMonitoring ❑Recovery 00 ft- 520 ft- PORTLAND.6ENTONUE SLURRY
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 69.0 ft. 84.0 rt' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑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,sod/mck type,gmin sin,etc.
0.0 ft• 12.0 rt. BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 10/04/21 Well ID# CP-10D 12.0 rt• 33.0 ft. BROWN SILTY SAND
Sa.Well Location:
33.0 rt' 50.0 rf DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION 50.0 ft- 84.0 ft. PWR
Facility/Owner Name Facility ID#(ifaPPlicable) f. ft.
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3195 PINE HALL ROAD BELEWS CREEK 27009 rt. a.
Physical Address,City,and Zip ft. ft. JAN 2 4 202?
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-62.0-69.0 FEET
***U-PACK SCREEN***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
360 28' 05.30" N 800 06' 53.46" W Wit,., r---
11/22/21
6.Is(are)the well(s): TIPermanent or ❑Temporary Signature of Certified Well Contractor Date
By.signing this Jorm,/hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15No 15A NCAC 01C.0/00 or 15A NCAC 01C.0200 Well Construction Standards and that a cap),
f this is a repair,Jill out known well construction hilbrinevion and explain the nature of the of this record has been provided to the hell owner.
repair under`'21 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 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: 84•0 (ft.)
Vor multiple ovells list all depths iif'diJJereni(example-3@200'and 1 100') Submit this GW-1 within 30 days of well completion per the following:
34.0 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
lflraier level is above casing,use'.
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11.Borehole diameter: 6.0/10.0 (in) 24b. For Injection 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
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 27699-1 61 1
13b.Disinfection type: Amount: i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourcesf Revised 6-6-2018