GW1-2022-07980_Well Construction - GW1_20220826

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft ft
A - 2581
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIA\I ETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TIIBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable mell construction permits(i.e.1.11C,Counnt State,Variance,etc.) 0.0 ft. 140.0 ft. 6.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FRONK TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 140.0 ft' 160.0 fL 6.0 in.
.010 SCH 40 PVC
❑Geothermal(Heat ing/Cool i jig Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irri atoll ❑Wei Is> I00.000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 20.0 ft. AQUA GUARD SLURRY
IMMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a i licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 25.0 ft. 165.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/mck type,grain Size,ale.)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks)
0.0 ft. 5.0 f`' TAN SILTY SAND
4.Date Well(s)Completed: 08/17/22 Well ID# EX-74 5.0 ft. 24.0 ft. PWR
5a.Well Location: 24.0 f" 165.0 ft' ROCK
BELEWS CREEK STEAM STATION ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address,City,and Zip
rt. rt.
STOKES 21.RED1ARKS
Coumy Parcel Identification No.(PIN) BENTONITE SEAL- 20.0-25.0 FEET
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
SUMP•- 160.0- 161.0 FEET
(ifsrell field,one fat/long is sufficient) 22.Certification: ,
928909.9944 N 1681079.833 NY !:2/s z; G"r---
08/22/22
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this firm l herehr c•erg&that the irell(s)tress(here)con.sirucied in accordance i0th
7.Is this a repair to an existing well: ❑Yes or MNo 1511 NCAC 02C.0/00 or 15A NCAC 02C',0200 Wel/Caus'rrucliott,57mu1arcG'and that a copy
IJ7his is a repair.fill out known u ell construction iglortnonon and erpla/a the noarre afdte q/this record has been provided to the well oirner.
repair under-21 rennarks section or on the hack gl"this./brut.
23.Site diagram or additional well details:
8.For Geoprobe/DP•f or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional Ave L(: nStfl16110 rrI'
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach addition Itd.--it;n2ec MZAA•.l? It-
drilled: 24.SUBMITTAL INSTRUCTIONS
160.0 AUG2 6 2022
9.•multi well depth below land surface: 7 ' (ft.) Submit this GNV-1 within 30 days of well completion per the following:
l•br multiple u¢•l1+'list all depths'iJ'difJi<rent(ernnrple-3@_(J(1'mud_n100') i f 1_.�..% rt,"1. ( nil
10.Static water level below top of casing: 108.0 (ft) 24a. For All Wells: Original form to Division of Wat�filf2'usbu�psa( .i uV 0
/J'u'merlerel is ahnre caring,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,rotate,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(-pm) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201S