GW1-2022-08893_Well Construction - GW1_20220912

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 - 2S81
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
rt. rt. in.
Company Name i
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable it ell construct/on permits(i.e.UIC,Cnutrrst Slate,Variance,etc.) 0.0 ft. 140.0 ft- 6.0 in. SCH 40 PVC
3."'ell Use(check well use): R. ft. in.
Water Supply Well: FROM
SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 140.0 ft' 160.0 I'L 6.0 in-,
n' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Olndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrl ation ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 20.0 ft• AQUA GUARD SLURRY
091vionitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater 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)
OGeothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,sou/crock rain sim.etc.)
0.0 ft• 7.0 ft• BROWN SILTY SAND
A.Date Well(s)Completed: 09/01/22 Well ID# EX-33 7.0 rr. 13.0 ff TAN SILTY SAND
5a.Well Location: 13.0 ft. 36.0 ft' PWR
BELEWS CREEK STEAM STATION 36.0 ft. 165.0 ft• ROCK
Facility/Owner Namc Facility IDH(inapplicable) ft. ft. ;Y•'i� � P `rb�
319S PINE HALL ROAD BELEWS CREEK 27009
Physical Address.City.and Zip ft. ft. SEP v 2 M2
STOKES 21.REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL-20.0 25.0 FEET r Unil
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: SUMP - 160.0- 161.0 FEET
(if well field,one[at/long is sufficient) 22.Certification:
928923.5660 N 1681358.119 \�, 3 „ r-
09/07/22
6.Blare)the well(s): OPermanent or ❑Temporary Signature ofCertifred Well Contractor Date
Hp signi»q lhic fitrnt.l hereby ceni/j,that tire ire//(s)irac(irere)constructed in accordance with
7.Is this a repair to an existing well: 01'es or ON'o 15A NCAC 01C.a100 or 15A NC4C 01C.0100 Well Canrtnrction bYandards and that a copy
Iftbis is a repair,(ill out known well consirucvi in iglorniation and explain the nalnre nffile q/'this record has been provided to the mid/miner.
repair under v'21 remarks section or oil the back ofthic)brnt.
23.Site diagram or additional well details:
3.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.onh'I 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
9.Total well depth below land surface: 160.0 (ft.)
hor multiple ire/tr lint all deptts ifdi/ferenl(example-3@100'and 1 n l00') Submit this GW-I within 30 days,pf well completion per the folioaving:
26.7 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
l/water level is above casing.use">
4
IL Borehole diameter: 10.0 (in) tab. For Injection Wells: Copy to DWR, Underground InJ ection 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 departinent of the county where installed
j
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.field(gym) Method of test: `
Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
k
13b.Disinfection type: Amount:
i
r
Form GN'-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-201 R