GW1-2022-07219_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 I DESCRIPTION
A- 2581 ft. 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
ft. ft. in.
Company Name
16.INNER CASING OR TUBING Ne6tbermal closed-loon)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable we//construction permits(i.e.U1C County,State,Variance,etc.) 0.0 ft- 114.0 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 114.0 ft' 134.0 ft. 6.0 i- .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 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
TMonitoring ❑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 EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 25.0 ff• 135.0 fL1 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. fL
❑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/rack type,gmin size,etc.)
0.0 1- 18.0 ft. RED SILTY CLAY
4.Date Well(s)Completed: 07/06/22 Well ID# EX-69 18.0 32.0 ft. BROWN SILTY SAND
5a.Well Location: 32.0 f° 45.0 rr' TAN SILTY SAND
BELEWS CREEK STEAM STATION 45.0 fc, 59.0 ft. PWR
Facility/Owner Name Facility ID4(ifapplicable) 59.0 fr• 135.0 fL 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)
BENTONITE SEAL-20.0-25.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
SUMP- 134.0-135.0 FEET
(if well field,one hit/long is sufficient) 22.Certification:
928597.0851 N 1680703.339 W �:':Sr;,-, 0 --
07/18/22
6.Is(are)the well(s)• 151'ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)consiructed in accordance n iih
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Nell Conyveyl",Stg ,rds and that a cop),
If this is a repair,fill out known well construction b formation and explain the nature of tile ofthis record has been provided to the well ovner. `y- d I"-�4
repair under#11 remarks section or on the back oJ'this form. , 'A jt
23.Site diagram or additional well details: u••�
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide add itiA el�(:otgtr info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additlonaff''pages ssary.
drilled: 24.SUBMITTAL INSTRUCTIONS In(orm" t, .x'PfzG ,.q Unh
9.Total well depth below land surface: 134. (ft.) QJzjO^
For multiple wells list all depths ifdii ferent(example-3 ret 100'and 1@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 74.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
/f hater 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 27699-1636
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 276 99-1 61 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018