GW1-2022-10596_Well Construction - GW1_20221122

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES k
Well Contractor Name FROM TO I DESCRIPTION
ft. ft.
A - 2581
fr. fr.
NC"'ell Contractor Certification Number 15.OUTER CASING for multi-cased wells UR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER' THICKNESS MATERIAL
in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: FROM TO -DIAMETER THICKNESS I MATERIAL
List all applicable well c•onstroctian pernins(i.e. UIC,Can ninly,Stale, f,'ariance,etc.) 0.0 ft. 140.E ft. 6.0 in' SCH 40 PVC
3.Well Use(check well use): fr. tr. in.
Water Supply Well: 17;SCREEN
❑Agricultural ❑Municipal/Public
FROM TO DIAMETER:. SLOT SIZE THICKNESS MATERIAL
140.0 ft. 160.0 ft' 6.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 113.GROUT
❑lrrl anon ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENTMET HOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 20.0 n- AQUA GUARD SLURRY
(EMonitoring ❑Recovery ft. ft.
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation
I9.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Ston %eater 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)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mckt e, rain size,etc.
0.0 ft. 9.0 ft. BROWN SILTY SAND
4.Date Well(s)Completed: 11/02/22 well ID# EX-79 9.0 rL 19.0 ft. TAN SILTY SAND
5a.Well Location: 19.0 ft' 41.0 ft. PWR
BELEWS CREEK STEAM STATION 41.0 ft. 165.0 ft. ROCK
Facility/Owner Name Facility IDtt(if applicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address,City,and Zip R. ft.
STOKES 21.REMARKS (.Arai
County Parcel Identification No.(PIN) BENTONITE SEAL-20.0-29RoEE�1"`ri�,•:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
SUMP- 160.0- 161.0 FEET
(if well field,one lat/Iovg is sufficient) 22.Certification:
929252.03 N 1682484.67 W
11/07/22
6.Is(are)the well(s): IEPermanent or ❑Temporary Signature of Certified Well Contractor Date
1 v.signing this Jiirm,/hereby ceritfy that the we//(s)was(were)constructed in accordance will)
7.Is this a repair to an existing well: ❑Yes or 15No 15A NCAC 02C.0100 or 15A NC'AC 62C.0200 Well Construction Standards and that a cop9
lfihis is a repair,fill out known well construction inlinrntoion and explain the nature a(the a/this record has been provided m the well oumer.
repair under '21 remarks section or on the back ojnhis./brnt.
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 into
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)
1-or umhiple urlla list o//depths ifdi(jerent(example-3«,200,and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 69.9 (fi) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
1l waler level is above casing,use
11.Borehole diameter: . 10.0 (in.) 24b. For Injection Wells: Copy to'DWR,Underground Injection Control(IUC)
Program. 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR
24c.For Water Supply and Open-Lo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push.etc.) op county environmental.health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.,For Water Wells producing over 100,'00 GPD: Copy to DWR..CCPCUA
Permit Program, 1611 MSC,Raleigh NC 27699-1611
13a.Yield(gpm) Method of test: .
13b.Disinfection type: Amount:
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Form GW-I North Carolina Department or Environmental Quality-Division of Water Resources f Revised 6-6-2018
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