GW1-2022-01408_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES I €
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 2581
rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for molt*-cased wells OR LINER if a licablRI
e
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATEAL
ft. ft.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Lis!all applicable well construction permits(i.e.UIC.County,State,Variance,etc.) 0.0 ft- 43.0 ft- 1.0 1n. SCH 40 PVC
3.Well Use(check well use): fr. tr. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 43.0 rt. 53.0 ft' 1.0 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 ation ❑Wells> 100,000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 34.0 ft' PORTLANDBENTOWE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. fr.
❑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 40.0 rt 53.0 rt' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑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/mck type, min size,etc.
0.0 ft 10.0 rr BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 11/22/21 Well ID# FGDLFPZ-21 10.0 rt 28.0 rr. BROWN SILTY SAND
5a.Well Location: 28.0 ft' 31.0 ft. DARK BROWN SILTY,SAND,, - r
BELEWS CREEK STEAM STATION 31.0 ft 53.0 ft-
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. 2
3195 PINE HALL ROAD BELEWS CREEK 27009
Physical Address,City,and Zip
ft. ft.
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 34.0-40.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
360 27' 25.41" N 800 05' 59.74" W !::2 Sr1z- Ow- 12110121
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,1 hereby certify that the well(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [5No 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Consvrucvion Standards and that a cow
f(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: 53.0 (ft.)
For multiple wells list all depths ifdJJerent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
43.0 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
1f water level is above casing,use' .
11.Borehole diameter: 6.0 (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 Liver 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:
Form GW-I North Carolina Deparhnent of Environmental Quality-Division of Water Resources Revised 6-6-2018