GW1-2022-09085_Well Construction - GW1_20220926

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES 1
Well Contractor Name FROM TO DESCRIPTION
A - 2581
NC Well Contractor Certification Number 1 15.OUTER CASING for multi-iased'wells OR LINER if a licable
GEOLOGIC EXPLORATION SEP 202 FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
hi' "^� ""'j t N 16.INNER CASING OR TUBING(geothermal closed-loop)
l✓.i 2.Well Construction Permit FROM TO DIAMETER THICKNESS MATERIAL
#:
List all applicable ue//constriction pernias(i.e.1/IC,Countlr.State,Variance,etc'.) 0.0 ft. 140.0 ft. 6.0 in- SCH 40 PVC
3.Well Use(check well use): fr. fr. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 140.0 ft- 160.0 ft' 6.0 in. i .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells> I00.000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 20.0 ft- AQUA GUARD SLURRY
[EMonitoring ❑Recovery ft. ft.
injection Well: ft. tr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage 25.0 ft• 165.0 ft. 20-40. FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control R. fr.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(1-leatine/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/mck type,grain sae,eic.l
0.0 fr. 0 fr. BROWN SILTY SAND
4.Date Well(s)Completed: 09/1 5/22 Well ID# EX-56 7.0 IL 15.0 ft- TAN SILTY SAND
5a.Well Location: 15.0 ft' 21.5 ft- PWR
BELEWS CREEK STEAM STATION 21.S ft- 165.0 ft- ROCK
Facility/Owner Name Facility I DO(ifapplicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. f3.
Physical Address.City,and Zip ft. ft.
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 20.0-25.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: SUMP- 160.0- 161.0 FEET
(if well field,one[at/lone,is sufficient) 22.Certification:
929003.7490 N 1681186.762 11, !:2sr1:;.. -
09/19/22
6.Is(are)the well(s): (EPermanent or ❑Temporary Signature ofCerlified Well Contractor Date
Hysigning this farm.l herehr certify that the orl!(s)eras(were}constructed in accordance with
7.Is this a repair to an existing well: 01'es or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 We//('an.vrucrian,SYandardc and r/rot a rapt
ll this is a repair.Jill out knmrn yell c•ousiruction inJnrnimion and explain the aware ofdte uflhis record has been provided nt the u'e/l owner.
repair'tattler A21 remarks.section or on the hack o/'this 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 construction intit
construction.only 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.)
/;'or nadtiple wells list all depths ifdllfereni(example-3 cc 200'and 2 cr 100') Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: 21.29 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR).
iJlrater/err/is rrhure c•n.ciq�.useinformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
'.. I
i
0.O 24b. For Injection Wells: Copy tojDWR, Underground Injection Control (IIJC)
I1.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12. \'ell construction method: AIR 24c.For Water Supply and Open-Loon Geothermal Return Wells:Copy to the
(i.e.auger.rotary.cable.direct push,etc.) county environmental health department otthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
I
13b.Disinfection type: Amount:
t
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources. Revised 6-6-2018
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