GW1-2022-07214_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. ft.
A - 2581
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UiC,County,Stare,Variance,etc.) 0.0 ft. 90.0 ft- 6.0 In' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE-1 THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 90.0 ft 110.0 ft. 6.0 en• .010 SCH 40 1 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 1t. I 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
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
OAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMEIHOD
❑Aquifer Test ❑StormwaterDrainage 25.0 ft- 115.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. 1L
❑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,soil/mck type,grain sae,etc.
0.0 ft. 8.0 ft. BROWN SILTY SAND
4.Date Well(s)Completed: 07/08/22 Well ID# IW-8 8.0 ft. 15.0 ft. TAN SILTY SAND
5a.Well Location: 15.0 ft, 57.0 It- PWR
BELEWS CREEK STEAM STATION 57.0 it• 115.0 ft• ROCK
Facility/Owner Name Facility lD#(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:
(ifwell field,one[at/long is sufficient) 22.Certification:
928409.3093 N 1680938.550 W �;,,, tr,�1,,,�--
07/18/22
6.Is(are)the weil(s): [EPermarient or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the wells)u•as(were)consirucied in accordance with
7.Is this a repair to an existing well: ❑Yes or 15No 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a cap),
If li i.s 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. `�. ' f!ram
repair tinder 21 remarks section or at the back of this form. ,L Mp g 4 I0.�
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 elhco �t�}�}ion info
construction,only l GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attacijiditnaL'pa �5[it?necessary.
drilled: 24.SUBiMITTAL INSTRUCTIONS
1100 ►rtterma:io� Pr,� '9 unit
.
9.Total well depth below land surface:
For multiple wells list all depths ifdii&rew(example-3Ca 100'and 2@100') (ft.) Submit this GW-I within 30 days of well completion�ier Itre towing:
10.Static water level below top of casing: 91.5 (ft) Information
For All Wells: Original form to Division of Water Resources (DWR),
if water level is above casing,use"+"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 10.0 (in) 24b. For Infection 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 27699-1 6 1 1
13b.Disinfection type: Amount:
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018