GW1-2022-01405_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
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 2581
rc. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
tt. fr. I in.
Company Name
16.INNER CASING OR TUBING ebthermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(11C.County,State,Variance,etc) 0.0 rt• 43.0 tt. 1.0 ' SCH 40 PVC
3.Well Use(check well use): fr. ft• in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public 43.0 ft' 53.0 ft' 1.0 1°' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑ifrl anon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fr• 35.0 rr. PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery
Injection Well:
rt. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 41.0 ft- 53.0 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 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
0.0 ft. 10.0 ft. BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 11/19/21 Well ID# FGDLFPZ-22 10.0 ft- 28.0 ft- BROWN SILTY SAND
5a.Well Location: 28.0 ff 31.0 ff DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION 31.0 ft 53.0 ft• ` PWR,-,(--I'} '
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. -
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. rL JAN 2 4 262
Physical Address,City,and Zip ft. ft.
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-35.0-41.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
360 27' 23.37" N 800 05' 66.29" W !:2Sr%i,- -r--
12/10/21
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisJornt,I hereby certify that the we//(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.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 4/this record has been provided to the well owner.
repair under 21 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: 53.0 (ft.)
For multiple wells list all depths tfdifferent(example-3 a@200'and 2 c@i 100') Submit this GW-1 within 30 days of well completion per the following:
47.0 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: 6.0 (in.) 24b. For Infection 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 over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018