GW1-2022-07217_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 Contractor Certification Number 15.'OUTER CASING for multi-cased wills OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER TH[C1avESS MATERIAL
ft, fL in.
Company Name
16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 110.0 ft. 6.0 tn• 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 ❑MunicipaVPublic 110.0 ft. 130.0 ft' 6.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑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
INMonitoring ❑Recovery ft. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licahle
❑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 421 Remarks) FROM To DESCRIPTION color,hardness,sail/rack type,irmin size,etc.)
0.0 ft. 14.0 ft. BROWN SILTY CLAY
4.Date Well(s)Completed: 07/05/22 Well ID# EX-63 14.0 ft. 25.0 ft. TAN SILTY SAND
5a.Well Location: 25.0 ft. 63.0 tt' PWR
BELEWS CREEK STEAM STATION 63.0 ft, 135.0 f►• ROCK
Facility/Owner Name Facility IDII(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) BENTONIfE 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 Wilting is sufficient) 22.Certification:
928515.8311 N 1680814.015 Nrl;,__ r--
07/18/22
6.Is(are)the well(s): (EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this fornt,I hereby certify 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 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under 921 remarks section or on the back ofthis form. •`�"""''N!
23.Site diagram or additional well detail F 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to providealitonal wel construc Q.info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also att� a tioyal gig if necessary.
drilled: J��ad
J �0'L
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 130.0 (ft) G 30 d Unh
For multiple wells list all depths ifdii ferent(example-3 c@r 200'and 2Q100� Submit this W-1 within days of well complet0,0.,WJWellowing:
61.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1 6 1 7
Ifsvater level is above casing,use"+"
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 27699-16 1 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018