GW1-2022-09062_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS - `
q"w 14.WATER ZONES I
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I�A,,,,✓ FROM TO- DESCRIPTION
Well Contractor Name Y a,�--. •"�'%�• '
ft. ft.
A - 2581 S r P ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a licable
GEOLOGIC EXPLORATION ; . ,, F ' `aril FROM TO DIAMETER THICKNESS MATERIAL
lfli + �'..
Company Name ft. in.
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit fl: FROM TO DIAMETER THICKNESS MATERIAL
List nll applicable.roll can.cn•uciion pernritc(te,UIC,Caranv.State, 1-'ariance,ete,) 0.0 ft. 140.0 ft• 6.0 in. SCH 40 PVC
3.Well Use(check well use): R. fr. in.
Water Supply Well: 17.SCREEN
PP y FROM TO DIAMETER: SLOT SIZE 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
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 rt• 20.0 tt• AQUA GUARD SLURRY
MMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if ti t rlicable
❑Aquifer Storage and Recovery ❑Salillity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 25.0 ft• 165.0 R' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control n. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM I TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft• 7.0 ft• RED SILTY CLAY
4.Date Well(s)Completed: 09/0$/22 Well ID# EX-51 7.0 ft. 17.0 ft. BROWN SILTY SAND
5a,Well Location: 17.0 ft- 25.0 ft' TAN SILTY SAND
BELEWS CREEK STEAM STATION 25.0 ft 44.0 rt• PWR
Facility/Owner Namc Facility I1311(ifapplicable) 44.0 rt• 165.0 rt. ROCK
3195 PINE HALL ROAD BELEWS CREEK 27009 ft ft
Physical Address.City,and Zip
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-20.0-25.0 FEET
SUMP- 160.0- 161.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one[at/long is sufficient) 22.Certification:
928902.5632 N 1681487.893 1V � - '`"' 09/12/22
6.Is(are)the well(s): OPermanent or ❑Temporary Sigtmture ofCerlified Well Contractor Date
Hy.signing ihir /iron,l here%v certyj-that the irell(s)tras(ivere)construciedl in ticcardance frith
7.Is this a repair to an existing well: 01'es or MNo 1.5.4 NC.4C 02C.0100 or/5A NCAC u2C.0200 Well Construction Standards and that a corn,
ifthin'is a repair,fill out kninin Ire//c'onsiructlon injitrnraiian and esplain the nature of die ajlhis record has been provided to the it owner.
repair under°21 remarks.section or an the back of ihi.s,jbrnt.
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 cotistrl10011 into
construction,only I GW-1 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.)
1•'or int,hiple Ire/h list all depths ifch(jirent(example-3 a 2011'and 2@/00') Submit this GW-I within 30 days of well completion per the following:
37.92 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 2 7699-1 6 1 7
I/hater level is above casing,use"
11.Borehole diameter: 10.0 (in) 24b. For Injection Wells: Copy toJDWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh;NC 27699-1636
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12.Well construction method: 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
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FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 161 1 MSC,Raleigh,NC 27699-16 1 1
13a.Yield(gpm) Method of test:
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13b.Disinfection type: Amount:
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Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources - Revised 6-6-2018