GW1-2022-07221_Well Construction - GW1_20220729

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14'.WATER.ZONES
i Well Contractor Name
FROM
ft. TO ft. DESCRIPTION
A - 2581 ft. ft.
NC Well Contractor Certification Number 15-OUTER CASING for multi-cased wells OR LINER if tiplicable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
.16.'INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,variance,etc.) 0.0 ft• 140.0 fl. 6.0 In' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FR.OSM REE TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 140.0 ft' 160.0 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
❑Im ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 20.0 fl. AQUA GUARD SLURRY
MMonitoring ❑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 I EMPLACEMENT METHOD
❑Aquifer Test . ❑StormwaterDrainage 25.0 ft. 165.0 ft. 20-40 FINESILICASAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothemlal(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,soillrock type,gmin sin,etc.
0.0 ft 10.0 ft BROWN SILTY SAND
4.Date Well(s)Completed: 06/28/22 Well ID# EX-13 10.0 ft 20.0 ft TAN SILTY SAND
5a.Well Location: 20.0 fL 48.0 ft' PWR
BELEWS CREEK STEAM STATION 48.0 ft 165.0 f° ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 rr. 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: SUMP- 160.0- 161.0 FEET
(ifwell field,one lat/long is sufficient) 22.Certification:
927994.4974 N 1681007.141 �� �rl;,;.G1' -
07/06/22
6.Is(are)the well(s)• liflPermartent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,1 hereby terrify that the well(s)was(were)constructed in accordance ividr
7.Is this a repair to an existing well: ❑Yes or INNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 I a copy
lfthis is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well ovine. w jf,
repair under 21 remarks section or on the back ofilus form.
• 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, itio&5-12&zatuction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS IntefAIQ�aOn Pmr.,G1 4ng Unh
160.0 7ti`�aicll OG
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3 rei 100'and 2 rr!00')
24.0 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 27699-1617
/fwaler level is abore 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 27699-161 I
13b.Disinfection type: Amount:
Form GWA North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018