GW1-2022-09084_Well Construction - GW1_20220926

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
Nell Contractor Name FROM TO DESCRIPTION
ft. ft. I
A - 2581 - t. ft. ft.
NC Well Contractor Certification Number �'`�-'(�'��°°~.,; 4d ' 11 t
IS.OUTER CASING(for multi-casedrsvells OR LINER if a tlicable
GEOLOGIC EXPLORATION (� FROM TO DIAMETE`R, THICKNESS MATERIAL
E P tt-Cfy� ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ��{1f;i
List ull applicable yell cansir)tc•iion per))ti[s(i.e.UIC.Conny.S7a1t;'Var1Ance•4 k-) 0.0 ft' 100.0 ft. 6.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. In.
17.SCREEN
Water Soppy'Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 100.0 fL 110.0 It. 6.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 130.0 ft. 150.0 ft. 6.0 in- .010 SCH 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 20.0 ft. AQUA GUARD SLURRY
INMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL F,MPLACEMENT METHOD
❑Aquifer Test ❑Stonnvvater Drainage 25.0 ft• 1 SS.0 ft. 20-46 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) 01 racer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION solar,hardness,soilh'ock type.gimin size,etc.
0.0 ft• 8 0 ft. BROWN SILTY SAND
4.Date Well(s)Completed: 09/1 5/22 Well ID# EX-57 8.0 ft. 14.0 ft' TAN SILTY SAND
Sa.Well Location: 14.0 rt' 17.0 ft PWR
BELEWS CREEK STEAM STATION 17.0 ft• 155.0 ft' ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 ft, ft.
Physical Address,City,and Zip
tr. fr.
STOKES 21.REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL- 20.0-25.0 FEET
SUMP- 1 SO.0- 151.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one[at/long is sufficient) 22.Certification:
929017.7509 N 1681216.119 W. -
09/19/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
1Hy signint this fiwn./hereby c•ertifi•that die u•ell(s)uw.s(mere)constructed in accordance trill)
7.Is this a repair to an existing well: 01'es or MNo l.iA NCAC 02C.0100 or/5A NCAC 02C.0200 Well Construction Standards and shot o cope
/f this is a repair.fill out knon'n well construction infitrniatiun and e.gAtin the nature of7he o/this record has been provided to the tee0 owner.
repair)order=21 renmrkv section or on the hack 0011i.S Jinn.
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 I GW-I is needed. Indicate TOTAL NUMBER of wells (atld'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 150.0 (ft.)
bier nwhiple.wells list all depdes ifd/ffereni(ezmnp/e-3@200'and 2@/00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 36.39 (ft) 24a, For All Wells: Original form to Division of Water Resources (DWR).
/f wok<r Jere/is ahure rori»,t,use g SC,Raleigh,NC 27699-1617
Information Processor Unit, 1617 M
10.0 24b. For Injection Wells: Copy tojDWR, Underground In ection Control(IUC)
11.Borehole diameter. (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.11'e11 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 ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing over 100,000 GPD:Copy to DWR.CCPCUA
13a.field(gpm) Method of test:
Permit Program,1611 MSC,Raleigh I NC 27699-1 61 1
13b.Disinfection type: Amount:
r
1
E
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018