GW1-2022-07216_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
fL A - 2581 ft.
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
fr. ft. in.
Company Name
16.INNER CASING OR TUBING e6thermal closed-loon)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable we//construction permits(i.e.VIC,County,State,Variance,etc.) 0.0 ft. 85.0 ft. 6.0 t"' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 85.0 fr' 105.0 ft 6.0 "' 1 .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fL 20.0 ft- AQUA GUARD SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if.alicableFROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 25.0 ft. 110.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional'sheets if necessa'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.)
0.0 f" 17.0 ft. RED SILTY CLAY
4.Date Well(s)Completed: 07/05/22 Nell ID# IW-32 17.0 ft. 20.0 ft. BROWN/TAN SILTY SAND
5a.Well Location: 20.0 ft. 57.0 rL PWR
BELEWS CREEK STEAM STATION 57.0 ft. 110.0 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 hit/long is sufficient) 22.Certification:
928583.3851 N 1680790.317 W �;,�, nj,�
07/18/22
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)tras(here)construcled in accordance with
7.Is this a repair to an existing well: ❑Yes or 25No iSA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f this is a repair,fill out known well construction information and explain fire nature of the of this record has been provided to the well owner. i
repair under#21 remarks section or on the back oJ'lhis form. E 91Nif E
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 ad i��i��}}nal cIVh, {�j� lion info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also atti�lL9tidit nai�pa��5 ccessaiy.
drilled:
24.SUBMITTAL INSTRUCTIONS Inform 0n Hr.c=azreng Unh
9.Total well depth below land surface: 105.0 (ft.) DVtQ/9OG
For multiple hells list all depths ifdoerenl(example-3«200'and 2 a@100') Submit this GW-I within 30 days of well completion per the following:
51.0 24a. For All Wells: Original form.to Division of Water Resources (DWR),
10.Stalk water level below top of casing:/Jlrnrer level is above casing,use (ft.) 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-Loon 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