GW1-2022-07210_Well Construction - GW1_20220729

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 2581 ft. ft.
N/C-Well Contractor Certification
Certification pNu/mber 15.OUTER CASING for multi-cased webs OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER' THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING.OR TUBING eotberma]closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 110.0 ft. 6.0 1° SCH 40 PVC
3.Well Use(check well use): ft. fr. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 110.0 ft. 130.0 ft' 6.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.'GROUT '
❑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
IFMonitoring ❑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 I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 25.0 ft, 135.0 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) El Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
� 0.0 ft- 11.0 ft• BROWN SILTY CLAY
4.Date Wells)Completed: 07/11/22 Well ID# EX-15 11.0 ft• 20.0 fL TAN SILTY SAND
5a.Well Location: 20.0 ff 55.0 fL PWR
BELEWS CREEK STEAM STATION 55.0 ft, 135.0 ft ROCK
Facility/Owner Name Facility iD#(ifapplicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address,City,and Zip ft. ft.
STOKES 21.REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL- 20.0-25.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: SUMP- 130.0- 131.0 FEET
(ifwell field,one lat/long is sufficient) 22.Certification:
928322.5892 N 1681049.606 W !:2S0z7_ 07/18/22
6.Is(are)the well(s): 2BPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the ire/1(s)was(u daudl¢¢uucil! m c�r�qmw
7.Is this a repair to an existing well: ❑Yes or [5No ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Con.lt 11ett S�kaOu�titd�s/+ 'c py
/f'this is a repair,Jill out known well construction information and explain the nature of the oJ'this record has been provided to the well owner. k�
repair under r21 remarks-section or on the back ofthis form.
23.Site diagram or additional well details: I'f 2 91022
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 into
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also Alt�ehratfdkibna( dg��;jf;�ec�s
drilled: '3'•"/i.lie,
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 130.0 (ft,)
For multiple wells list al/depths ifdii fereni(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
55.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
f water level is above casing,use"+"Static water level below top of casing: A) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lf
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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018