GW1-2022-06848_Well Construction - GW1_20220720

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
BRIAN THOMAS 14-.WATER ZONES.
FROM .TO DESCRIPTION
Well Contractor Name
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. I ft. I in.
Company Name 16.INNER CASING OR TUBING; eothermal closed-loo -
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' 120.0 n- 6.0 in. SCH 40 PVC
3,Well Use(check well use): ft. ft. in.
17.SCREEN. ._
Water Supply Well: FROM TO DIAMETER SLOTSIZE­ THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 120.0 ft• 140.0 ft' 6.0 in.,
n' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ' ft. in
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GRO.UT
❑Irrl ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENTMEiHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 25.0 ft- AQUA GUARD SLURRY
OMonitoring. ❑Recovery ft. ft.
Injection Well: ft. 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 ❑StormwaterDrainage 30.0 ft- 145.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control \ ft. 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,hardness,soil/rock e, rain sire,etc.
0.0 ft. 7.0 ft- RED SILTY CLAY
4.Date Well(s)Completed: 06/07/22 • Well ID# IW-22 7.0 It- 11.0 ft' BROWN SILTY SAND
5a.Well Location: 11.0 It' 35.0 ft- TAN SILTY SAND
BELEWS CREEK STEAM STATION 35.0 ft- 60.0 ft- PWR
Facility/Owner Name Facility ID#(ifapplicable) 60.0 ft• 145A ff RC�C-' a N^' �t iT
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
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Physical Address,City,and Zip ft. ft.
STOKES 21.RENIARKS
BENTONUE SEAL-25.0-30.0 FEET ;"
County Parcel Identification No.(PIN) , ,n tt4;t +J\1f
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lit/long is sufficient) 22.Certification:
928904.8766 N 1681566.032 Wn:�.. r
06/17/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify than the ivell(s)ivas(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or I9No 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe ofthis retard 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: 140.0 (ft.)
Ror multiple wells list all depths iifdifferent(example-3 a 00'and 2 a 100) Submit this GW-I within 30 days"of well completion per the following:
30.0 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"+"
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11.Borehole diameter: 10.0 (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 27699-1 6 1 1
13a.Yield(gpm) Method of test:
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13b.Disinfection type: Amount:
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Form GW-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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