GW1-2022-01403_Well Construction - GW1_20220124

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
1.Well Contractor Information:
BRIAN THOMAS IA.WATER ZONES k
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 2581 rt. 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
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.UIC,County,State,Variance,etc.) 0.0 ft- 22.0 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 22.0 ft' 27.0-ft'-
2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) I7Residential 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- 14.5 ft- AQUA GUARD SLURRY
INMonitoring ❑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 18.5 ft- 27.0 ft- 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,soil/rock type,grain sin,etc.
0.0 ft- 7.0 ft- 'BROWN SILTY SANDY CLAY
4.Date Wells)Completed: 1 O/O4/21 Well ID# GWA-19SB 7.0 ft- 18.0 ft- BROWN SILTY SAND
5a.Well Location: 18.0 ft. 22.0 ft- DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION 22.0 ft- 27.0 ft- tPWR
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1 ,.:S`: i
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft. -JAN 2 4
Physical Address,City,and Zip -
STOKES 21.REMARKS-
CountyParcel Identification No.(PIN) BENTONIfE SEAL 14.5 18.5 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***U-PACK SCREEN***
(if well field,one latilong is sufficient) 22.Certification:
360 29' 54.56" N 800 08' 24.91" w �rc;._
11/22/21
6.Is(are)the well(s)• OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 19No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1J'1his is a repair,fil/out known well construction information and explain the nature of the ofthis•record has been provided to the well oumer.
repair tinder'121 remarks section or on the back ofthis 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: 27.0 (R.)
For multiple wells list a//depths tJ*diiferent(example-3@a 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
20.0 24a. For All Wells: Original forrrl 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)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
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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
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: Amount: I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018