GW1-2022-06857_Well Construction - GW1_20220720

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS ..14;WATERZONEs
FROM TO DESCRIPTION
Well Contractor Name
ft. ft. I �
A - 2581 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi=eased,wells OR LINER if a licable
GEOLOGIC EXPLORATION ftft.
TO DIAMETER THICKNESS MATERIAL
ft. in.
Company Name
:16.INNER CASING OR TUBING- eofhermal closed-loop)
2.W¢iI Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 6.0 ft. 120.0 ft- 6.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 120.0 ft. 140.0 It- 6.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑IndustriaYCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 25.0 ft• AQUA GUARD SLURRY
IN Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
,19.SAND/GRAVELPACK ifa 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 addrtion`al sheets if rikessa'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gnin sire,etc:
0.0 ft. 6.0 ft. RED SILTY CLAY
4.Date Well(s)Completed: 06/07/22 Well ID# IW-21 6.0 ft. 16.0 ft' BROWN SILTY SAND
5a.Well Location: 16•0 ft- 30.0 ft' TAN SILTY SAND
BELEWS CREEK STEAM STATION 30.0 ft. 75.0 ft- PWR
Facility/Owner Name Facility ID#(if applicable) 75.0 ft- 145.0 ft' ROCK
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address.City,and Zip ft. ft.
STOKES 21.REMARKS
County Parcel identification No.(PIN)
BENTONIfE SEAL�-25.0-��30.'0 F�ET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
928885.0619 N 1681544.595 W :�,. jlkr �' �t +�
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,i hereby certify that the well(s)was(were)constricted in accordance with
7.Is this a repair to an existing well: ❑Yes or fNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
o this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the f
repair tinder P21 renarks 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-I 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
0
9.Total well depth below land surface: 140. (ft.) Submit this GW-1 within 30 days of well completion per the following:
ror multiple wells list all depths ifdifferent(example-3@200'and 2@100D
37.0 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:
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 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: ;
I
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
I ,