GW1-2022-10678_Well Construction - GW1_20221205

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
Well Contractor Name ";;, „h,,,J�-•�o FROPt TO I DESCRIPTION
A - 2581 ft. ft.
pr c � � 2022
NC Well Contractor Certification Number
i ^�i�fi f.�+:y�l�) 15.OUTER CASING for multi-cased wells OR LINER if a t 8icable)
GEOLOGIC EXPLORATION tnz, e(••'r" FROM TO DIAM ET THICKNESS MATERIAL
"7!3'I�yj ft, ft. iti.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable n'ell construction permits(i.e.UIC,Coungy.Stale,Variance,elc.) 0.0 ft- 140.0 ft. 6.0 In- SCH 40 PVC
3.Well Use(check well use): ft ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/PLtblic 140.0 ft' 160.0 ft' 6.0 in. 010 SCH 40 PVC
❑Geothermal(Fleating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD d AMOUNT
Non-Water Supply Well; 0.0 ft- 20.0 ft. AQUA GUARD SLURRY
OMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑AquiterTest ❑Stormwater Drainage 25.0 rt• 165.0 rt. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. I ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc,)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 tt• 9.0 rt• BROWN SILTY SAND
4.Date Well(s)Completed: 10/27/22 Well ID# EX-81 9.0 fr• 24.0 ft• TAN SILTY SAND
5a.Well Location: 24.0 rt• 83.0 tf PWR
BELEWS CREEK STEAM STATION 83.0 rt• 165.0 rt• ROCK
FacilindOwnerName Facility lD#(ifapplicable) ft. ft.
3195 PINE HALL ROAD BELEWS CREEK 27009 ft. ft.
Physical Address,City.and Zip ft. ft.
STOKES -21.REMARKS
Count}' Parcel Identification No.(PIN)
BENTONITE SEAL-20.0-25.0 FEET
ill.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
SUMP- 160.0- 161.0 FEET
(ifwcll field,one lat/long is sufficient) 22.Certification:
929305.14 N 1682563.87 W o-T- 10/31/22
6.Is(are)the well(s): MPernianent or ❑Temporary Signature ofCertified Well Contractor Date
By signing 1his farm,I hereby certify that the wellO was(were)constructed in accordance with
7. Is this a repair to an existing well: ❑Yes or MNo 1511 NC.4('02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and ihoi a copy
//'this is a repair,fill ao known well construction ii fornmlion and explain the nature o0he ofthis record has been provided to the well owner.
repair under=21 remarkv section a-on the back aJl his form.
23.Site diagram or additional well details:
S.For Gcoprobe/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 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: 160.0 (ft.)
1•br aulliplc we/1s lisi all depths iJ'e16tJercm(example-3@20'and 2@100') Submit this GWA within 30 days of well completion per the following:
73.85 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static crater level below top of casing: (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
if water level is obore casing,use
11.Borehole diameter: 10.0 (in) 24b. For Injection Well!: Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR i
24c.For Water Supply and Open-Loon Geothermal Return Wells:Copy to the
(i.e.auger,rotap'.cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells'prod ucin.,over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: `
Penn it Program, 1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: Amount:
Form G11'-I North Carolina Department orEnvironmeutal Quality-Division or Water Resources Revised 6-6-2018