GW1-2022-07392_Well Construction - GW1_20220809

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 4
BRIAN THOMAS MWATERZONES j,
Well Contractor Name
FROM TO I DESCRIPTION
A - 2581 fr. ft
NC Well Contractor Certification Number
15.OUTER CASING for mtdti-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I gin.
Company Name
16JNNER CASING OR TUBING eothermal closed-loon)
2,Well Construction Permit#: FROM TO DIAMETER! I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 105.0 IL 6.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: .17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 105.0 ff 125.0 ft• 6,0 '"'� .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.l
❑Industrial/Commercial ❑Residential Water Supply(shared) I8..GROUT
❑1rr1 ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 20.0 ft- AQUA GUARD SLURRY
RMonitoring ❑Recovery fr. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 25.0 ft- 130.0 ft- 20-40 J FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,gnin sim,etc.
0.0 ft- 13.0 ff• RED SILTY CLAY
4.Date Wells)Completed: 07/27/22 Well ID# EX-66 13.0 ff• 24.0 ft- BROWN SILTY SAND
5a.Well Location: 24.0 ft. 38.0 ft' TAN SILTY SAND
BELEWS CREEK STEAM STATION 38.0 ft• 63.0 ft• PWR
Facility/Owner Name Facility ID#(if applicable) 63.0 fL 130.0 ff ROCK ` L_ EH.Y E D
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address,City,and Zip ft. ft. AUFJ 0 9, 2
STOKES 2L REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL 20.0-25.0 FEET ;+ _L?,tit-
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
SUMP- 125.0- 126.0 FEET
(if well field,one hit/long is sufficient) 22.Certification: �
928721.2066 N 1681078.219 Wn;i„ (jlwr--
08/01/22
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)u•as(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f this 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.
repair under#21 reinarks section or on the back ofthis 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 additional well construction 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: i24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 125.0 (ft.)
l-or multiple wells list all depths ifili ferent(example-3@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: 81.0 (ft•) 24a. For All Wells: Original form to Division of Water Resources (DWR),
li water 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 27699-1611
13b.Disinfection type: Amount:
f
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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