GW1-2022-07213_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.
NC Well Contactor Certification Number is.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICIINESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loot))
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) 0.0 ft. 110.0 ft. 6•0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. 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
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 20.0 ft. AQUA GUARD SLURRY
IMMonitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL 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) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,gmin size,etc.
0.0 R• 8.0 ft. BROWN SILTY CLAY
4.Date Well(s)Completed: 07/21/22 Well ID# EX-70 8.0 ft• 20.0 ft. TAN SILTY SAND
Sa.Well Location: 20.0 ft. 59.0 fr' PWR
BELEWS CREEK STEAM STATION 59.0 fc• 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
Sb.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:
928646.2353 N 1680785.378 W !2:SnL---_ G- ,r
07/25/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,i hereby cert6ry that the well(s)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,fill out known well construction injorntatlon and explain the nature of the ofdtis record has been provided to the well owner. tD
T �y^���
repair under 921 remarks section or on the back ojthis form. -{ ,LY��.y
23.Site diagram or additional well detai :`s}-- "`
8. You may use the back of this page to provide additional e l c.tion in
construction,
For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (aee ven Remarks B Y l a s Box).You may also L a tio a if necessary.
9
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells dd'S Or i R ��`
drilled: 24.SUBMITTAL INSTRUCTIONS
A�A:aC1 P
Submit this GW fO:.AS3"�J l�Rti
9.Total well depth below land surface: 130'0 (ft.) l ti"d>rlthr e0'C
For multiple wells list all depths ifelfferent(example-3 a 200'and 2@100') -]within 30 days of welll c coompletion per the following:
10.Static water level below top of casing: 54.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater 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-I636
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:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018