GW1-2022-01398_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 DESCRIPTION
A-2581 ft. ft
ft I ft
NC Well Contractor Certification Number 15.OUTER CASING for multitased wells OR LINER if a licable
Geologic Exploration, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
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 35.0 ft 2 1°' SCh 40 PVC
3.Well Use(check well use): 45.0 ft 50.0 ft- 2 In. SCh 40 JPvc
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35.0 n 45.0 ft 2 in. .010 SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 tt 21.0 ft Aquaguard Slurry
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 32.0 ft 50.0 ft 20-40! IFine Silica Sand
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0.0 ft 50.0 ft- ASh �.. .
4.Date Well 11/10/21 s)Completed: Well ID#AB-PZ-33 ft ft
5a.Well Location: ft ft
Belews Creek Steam Station ft ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
3195 Pine Hall Road Belews Creek 27009 ft ft
Physical Address,City,and Zip ft ft
Stokes 21.REMARKS
County Parcel Identification No.(PK Bentonite Seal 21.0-32.0 feet
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 5'sch�40 PVC Sump
(if well field,one lat/long is sufficient) 22.Certification'
36 28' 97.95" N 80 07'44.84" W
6.Is(are)the well(s): [5Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo I5A NCAC 02C.0100 or 1 SA NCAC 01C.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 of this record has been provided to the well 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: 50.0 (ft) 1
For multiple wells list all depths if di[j'erent(example-3 a200'and 2@I00� Submit this GW-1 within 30 days of well completion per the following:
8.0 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: 8.0 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Auger Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: g 24c.For Water Supply and Open I-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
r
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWIt CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018