GW1-2022-01707_Well Construction - GW1_20220131

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES t
Well Contractor Name FROM TO DESCRIPTIONft. ft. p
A - 2581
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0.0 ft• 34.0 ft. 6.0 i" SCH 40 PVC
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.l/1C,Coun(y.State, Variance,etc.) 0.0 ff 59.0 ff 2.0 i"' SCH 40 PVC
3.Well Use(check well use): tt. R. in.
17.
Wafer Supply Well: FROM SCREENTO DIAMETER, SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 59.0 ft' 69.0 ft' 2.0 t"' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial El Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wei Is>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft, 47.0 ft. AQUA GUARD SLURRY
OMonitoring ❑Recovery 0.0 ft. 34.0 ft' PORTIANDSENTONRE SLURRY
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 54.0 ft. 69.0 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/track type,grain size,etc.
0.0 fL 8.0 fr• BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 1 0/04/21 Well ID# CCR-13BRA 8.0 fr. 14.0 ff BROWN SILTY SAND
5a.Well Location: 14.0 ft• 19.0 ft' DARK BROWN SILTY SAND
BELEWS CREEK STEAM STATION 19.0 ft• 29 0 ft• PWR•-
Facility/Owner Name Facility ID9(ifapplicable) 29.0 ft. 69.0 ft. ROCK
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft. N 31 2077
Physical Address,City,and Zip
rt. ft.
STOKES 21.REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL 47.0
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***U-PACK SCREEN***
(if well field,one lat/long is sufficient) 22.Certification:
360 29' 82.70" N 800 08' 17.02" W 3n:.-_ 11/22/21
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
Hy signing this farm,l herehy certify that the well(s)was(were)eonstruc•ted in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copv
if this is a repair,fill oat known ire/l construction information and explain the nature of the cf7his record has been provided to the trell'oumer.
repair under�21 renarkv section or on the back of7his 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 I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessarN.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 69.0 (ft)
hor muhiple irel/s/ist all depths ifdyferent(example-3 rt 200'and 2@100') Submit this GW-1 within 30 days of,well completion per the following:
10.Static water level below top of casing: 48.0 (ft) 24a. For All Wells: Original form Ito Division of Water Resources (DWR),
/ju•atet•level is above casing.use„-,.
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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 over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
I
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Foam G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018