GW1-2022-09089_Well Construction - GW1_20220926

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES p
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 2581
NC Well ContraaorCertirication Number M I5.OUTER CASING for multi-cased;,vells OR LINER if a Hirable)
GEOLOGIC EXPLORATION _ '�<• FROM TO DIAMETER THICKNESS MATERIAL
,� ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loo t
2.Well Construction Permit# Irli;> [F.R.,OM TO DIAMETER THICKNESS MATERIAL
Lisi till applicable ire//consiruclion permits(i.e.(./lC.Cann�� YO(�^drari^rce'i%F) ii: O.O ft. 120.0 ft. 6.0 in. SCH-40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 7 SCREENM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 120.0 fr' 140.0 fr, 6.0 in.
010 SCH 40 PVC
❑Geothermal(Heat i ng/Cool i ng Supply) ❑Residential Water Supply(single) R. 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 ft• 20.0 fL AQUA GUARD SLURRY
@51vionitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a licablc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL E11PLACED1 ENT hI ETIIOD
❑Aquifer Test ❑Stormwater Drainage 25.0 ft• 145.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. rt.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hairiness,soilimck type, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft• 7.0 fr• BROWN SILTY SAND
4.Date Well(s)Completed: 09/14/22 Well 1D# IW-24 7.0 ft• 17.0 fl• TAN SILTY SAND
ia.Well Location: 17.0 ft' 36.5 fr' PWR
BELEWS CREEK STEAM STATION 36.5 ft• 145.0 fr• ROCK
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. a•
Physical Address.City.and Zip ft. ft.
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-20.0-25.0 FEET
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one]at/long is sufficient) 22.Certification: �
928903.2700 N 1681165.708 NV Z.)t'L�, 09/19/22
6.Blare)the well(s): OPermanent or 01'emporary Signature of Certified Well Contractor Date
lfv s'ig,niog dris Jirrin.l hereliv ceriil.j:that the it was 6,ere)constructer/in nceordnnce virh
7. Is this a repair to an existing well: ❑Yes or ONo /?.4 N'(:4('I/?('.0/(/O ur/iA Ar('A('(I7(',0:0(I tti'elI(nnovructiun,Stuudardc miJ t/tin a ruler
lJ this is a repair./ill om knoirn❑'ell consbvevion inlbrnuliun and explain the nartu'e of the of this record has been provider/to the it ell owner.
repair under?21 remurks.section or tin the buck uJ'thi.c Jiirnr.
23.Site diagram or additional well(details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Yells having the same You may use the back of this page to provide additional well construction into
construction,only 1 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: 140.0 (ft.)
/ p f ZT ( / @2 ,C ) Submit this GW-I within 30 days of well completion per the following:
l�iir nndti dr u'c•!/s list till du the i rh event erne i/e-?r,_(/Il'nn<!_rt 10/1' P P g
31.29 24a. For All Wells: Original form to Division of Water Resources (DW'R).
10.Static water level below top of casing: (fL) Information Processing Unit, 1617 MSC,Raleigh,NC 2 7699-1 6 1 7
tierce/r re/is nhure c•usirrg use...
10.0 24b. For Injection Wells: Copy to,DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in.) 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.iotaty.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
I3a.Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleigh;NC 27699-161 1
13b.Disinfection type: Amount:
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Form G W-I North Carolina Depar'tmcat of Environmental Quality-Division of Water Resources Revised 6-6-2018