GW1-2022-06858_Well Construction - GW1_20220720

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WELL.CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
BRIAN THOMAS 14.WATER-ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 2581
NC Well Contractor Certification Number 15.'OUTER CASING for multi-cased'wells OR LINER ifa licatile
GEOLOGIC EXPLORATION FAOM TO DIAMETER THICKNESS ' MATERIAL
fr. ft. ; in
Company Name
16:-INNER CASING OR TUBING` eothermal closed-loop)'
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well consiruciion permits(i.e.UIC,County,Slate,Variance,etc) 0.0 ft. 95.0 ft- 6.0 SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 95.0 ft• 1115.0 ft' 6.0 1-2, .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. I f j in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT---,'
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft, 20.0 ft, AQUA GUARD SLURRY
fflMonitoring ❑Recovery fr. fr.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:'SAND/GRAYEL:PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 25.0 ft- 120.0 ff• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING.LOGS attach addi Tonal+slieets if necessa -
1 -
FROM TO DESCRIPTION color,hardness,soil/rock t e, ruin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain tinder#21 Remarks)
0.0 a• 8.0 ft. RED SILTY CLAY
4.Date Well(s)Completed: 06/17/22 Well ID# IW-g 8.0 ft• 25.0 fr' BROWN SILTY SAND
5a.Well Location: 25.0 ft' 71.0 ft' PWR
BELEWS CREEK STEAM STATION 71.0 ft, 120.0 ft. C' K "�•��j�tj F�n
Facility/Owner Name facility ID11(if applicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 rt. ft.
Physical Address,City,and Zip
STOKES :21iREMARKS ':.''..: "., ., .r1,.• ., . `r .=I?h9 1 �n
County Parcel Identification No.(PiN) BENTONITE SEAL-20.0-•QS'OtF'EET'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hit/long is sufficient) 22.Certification:
928497.6721 N 1681034.477 W
06/24/22
6.Is(are)the well(s)• INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200(fell Construction Standards and that a copy
If ihis is a repair,fill oul known ivell construction information and explain the nature of the ofihls record has been provided to the well owner.
repair larder r'21 remarks section at-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 I GW-i is needed. Indicate TOTAL NUMBER of wells (add'See Ove?in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 115.0 (ft.)
For inulliple wells list all depths ifdifferein(example-3 a200'and 2@100') Submit this GW-1 within 30 days'of well completion per the following:
10.Static water level below top of casing:
62.0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwater level is above casing,use^+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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 etc.) AIR
(i.e.auger, 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
.cr,rotary,cable,direct push, - county environmental health department of the county where installed
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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(gpnl) Method of test:
13b.Disinfection type: Amount:
form G W-I North Carolina Department of Environmental Quality-Division of water Resources Revised 6-6-2018