GW1-2022-07211_Well Construction - GW1_20220729

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS '14.WATER ZONES
.
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 2581 ft. IL
NC Well Contractor Certification Number 15.OUTER.CASING for mi-casedwls OR LINER ifalicable
GEOLOGIC EXPLORATION DMTR THICKNE
MATERIAL
ft. ft. in.
Company Name 16:INNER CASING OR TUBING(geothermal closed-loop).
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS .MATERIAL
List all applicable well construction permits(t.e.U1C,County,State,Variance,etc.) 0.0 ft. 85.0 ft. 6.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN ' -
PPy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 85.0 ft• 105.0 It. 6.0 in. .010 SCH 40 PVC
❑Geothenmal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 20.0 It. AQUA GUARD SLURRY
MMonitoring ❑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 ❑Stormwater Drainage 25.0 ft. 110.0 It. 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,soillrock type,gnin sae,etc.
0.0 It. 18.0 ft. BROWN SILTY SAND
4.Date Well(s)Completed: 06/28/22 Well ID# IW-46 18.0 ft. 37.0 ft. TAN SILTY SAND
5a.Well Location: 37.0 It. 53.0 It' PWR
BELEWS CREEK STEAM STATION 53.0 ft. 11.0.0 ft. ROCK
Facility/Owner Name Facility ID#(if applicable) 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:
(if well field,one lat/long is sufficient) 22.Certification:
928300.9055 N 1680928.532 W 07/06/22
6.Is(are)the well(s): 25Permanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,!hereby certify that the svell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
/fthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner. D
repair under Ul rentarks section or on the back of this form. � f
23.Site diagram or additional well details..R ti.-.
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 att�}tLdcio&I @gisaif necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
105.0 ln€cftrla:aOO Pr�: ".��e9 Una
9.Total well depth below land surface: (ft.) Submit this GW-I within 30 days of well completi�'tt��r cf0owing:
For multiple wells list all depths ifdi/j"erent(example-3 ct-00'and 1@100')
10.Static water level below top of casing: 51.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
ljsraler 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: 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 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018