GW1-2022-10599_Well Construction - GW1_20221122

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS
14.WATER ZONES 1' i
Well Contractor Name FROM TO DESCRIPTION
A - 2581
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR-LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
fr. ft. I I in.
Company Name - - - -
16.INNER CASING OR TUBING eotherma[closed-loop)
2.Well Construction Permit#• FROM TO I DIAMETER THICKNESS I MATERIAL
List all cippliccrhle ire!!eonsiruclioit perntil.r(i.e.(.IIC,Counly.Slate, Variance,etc'.) 0.0 fit- 140-0 f'• C.0 in• SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 140.0 ft- 160.0 f'• 6.0 .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. ini
❑Ind ustrial/Commercial OResidential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells> 100,000 GPD .FROM. TO MATERIAL EMPLACEMENT METHOD R AMOUNT
Non-Water Supply Well: 0.0 f' 20.0 f' AQUA GUARD SLURRY
OflMonitoring ❑Recovery
Injection Well: It. ft.
❑Aquiter Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormxvater Drainage 25.0 1'• 170.0 ft- 2b-40 FINE SILICA SAND
OExperimental 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,hairiness,soil/rock tv e,grain size,etc.
0.0 ft. 7.0 ft- BROWN SILTY SAND
4.Date Well(s)Completed: 11/04/22 Well ID# EX-75 7.0 ft, 17.0 ft. TAN SILTY SAND
5a.Well Location: 17.0 St• 57.0 ft- PWR
BELEWS CREEK STEAM STATION 57.0 f' 170.0 ° ROCK ip
Facility/Owner Name Facility ID9(ifapplicable) F.,�. �
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft. 22
Physical Address.City,and Zip ft. ft.
STOKES 21..REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL- 20.0-25.0 FEET D+^O,'nOC
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
SUMP- 160.0- 161.0 FEET {.
(if welt Field.one fat/long is sufficient) 22.Certification:
929306.12 N 1682257.31 W (lw --
11/07/22
6.]slate)the well(s): MPermanent or ❑Temporary Signature ofCcnified Well Contractor Date
By.signing ihis fiirtn,/hereby Geriyy that the mell(r)u•as(it ere)consirucied in accordance Priih
7.Is this a repair to an existing well: ❑Yes or ONo 15.4 NCAC 01C.0100 or 15A NCAC 01C.0100 Nell Cons'irucuon StdndartG and that a cope
l/this is a repair,(ill out known it construction h fiirntalion and explain the nature of the gl'thi.s record has been provided to the tre//nu•ner.
repair under;'1l remarks section or on the hack a/ihis form.
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 (add'Sce Over'in Remarks Box).You may also attach additional pages if necessan.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 160.0 (ft.)
r p / 1 ( p @ ) Submit this GW-1 within 30 days of well completion per the following:
l'ur nrulu /c•u•e/Ls li.el nll depths i di ereni exnm /e-i r 100'and 2 t l00' Y P P g
10.Static water level below top of casing: 49.63 (ft) 24a• For All Wells: Original forth to Division of Water Resources (DWR),
(firmer/ere/is obare casing,use Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:
10.0 24b. For Injection Wells: Copy to!DWR,Underground Injection Control (IUC)
(in.)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR(i.e.auger,rolary,,cable.direct push,etc.) 24c.For Water SuppIv and Open-Loop Geothermal Return p)'
Wells:Co to the
county environmental health department of the county where installed
FOR W.ATER:St1PPLY WELLS ONLY: 24d. For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleigh;NC 27699-1 61 1
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13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources r Revised 6-6.2018