GW1-2022-01401_Well Construction - GW1_20220124

1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
A - 2581
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased'wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETERi THICKNESS MATERIAL
0.0 ft• 40.0 ft- 6.0 j in SCH 40 PVC
Company Name 16.INNER CASING OR TUBING cothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,Stale,Variance,etc) 0.0 ft• 54.0 ft. 2.0 i sn' SCH 40 PVC
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 54.0"' 64.0 ft. 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 atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 37.0 ft. AQUA GUARD SLURRY
25Monitoring ❑Recovery 0.0 ft. 40.0 ft' PORTtANDBENTONITE SLURRY
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 49.0 ft• 64.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. I ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hnrdness,soil/stucktype,grain size,etc.
0.0 It. 8.0 ft. BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 10/04/21 Well ID# GWA-24BRD 8.0 It. 19.0 ft. BROWN SILTY SAND
5a.Well Location: 19.0 ft' 44.0 fL DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION 44.0 ft- 64.0 It- ,PWR
Facility/Owner Name Facility ID#(if applicable)
ft. ft. J.
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft. Aff 2 42uc.r.^?
Physical Address,City,and Zip ft. ft.
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-37:0-.49.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***U-PACK SCREEN***
(ifwell field,one lat/long is sufficient) 22.Certification:
360 30' 06.68" N 800 07' 67.06" W '��z.-- ---
11/22/21
6.ls(are)the well(s)• Permanent or ❑Temporary Signature of Certified Well Contractor Date
By sibming this Jorm,1 hereby certify that the we//(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IMNo 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
/jlhis 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 P21 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-I 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: 64.0 (ft)
For multiple welts list all depths ii diJJeretn(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
35.0 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 waler level is above casing,use"4
11.Borehole diameter:
6.0/10.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,INC 2 76 99-1636
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 I ver 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
I
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018