GW1-2022-07212_Well Construction - GW1_20220729

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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.A - 2581 ft.
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells R LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER OTHICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction pernNls(i.e.U1C,County,Slate,I"ariance,etc.) 0.0 ft. 120.0 ft. 6.0 'n' I SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1�.SCREEN
❑Agricultural ❑Municipal/Public KN
FROM TO DIAMETER SLOT SIZE THICESS MATERIAL
120.0 fL 140.0 fr. 6.0 'n' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) "' It. in
❑Industrial/Commercial ❑Residential Water Supply(shared) ft.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
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 / ❑StormwaterDrainage 25.0 ff• 145.0 fL 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control tt. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessarO
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,suil/mck type,grain size,etc.
0.0 fr• 17.0 ft. RED SILTY CLAY
4.Date Well(s)Completed: 07/1 3/22 Well ID# EX-16 17.0 ft• 29 0 ft. BROWN SILTY SAND
5a.Well Location: 29.0 ft• 45.0 ft. TAN SILTY SAND
BELEWS CREEK STEAM STATION 45.0 1" 60.0 ft. PWR
Facility/Owner Name Facility ID#(if applicable) 60.0 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-20.0-25.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
SUMP- 140.0- 141.0 FEET
(if well field,one lit/long is sufficient) 22.Certification:
928402.2460 N 1681098.227 W �;�., �jl --
07/18/22
6.Is(are)the well(s): ITPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was r�ryt rruct uLinE,,,` c u t +
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Wel!C nslrudietV;1,'�ardb at 6 t an y
If This is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under�21 remark8-section or on the back ofihis form. J I J L 2 J 2022
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 i aif i 0.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may alsolattStfEPee"R�4�-MI? � j�.
drilled: 24.SUBMITTAL INSTRUCTIONS DG
9.Total well depth below land surface: 140.0 (ft.)
For ntulliple wells list all depths ifdierenl(example-3 a 00'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 82.0 (ft,) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwater lorel is above casing,use".
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I1.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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018