GW1--04756_Well Construction - GW1_20230724

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ; -
1.Well Contractor Information: .. .
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BRIAN THOMAS 14.WATERZONES' - .
Well Contractor Name
FROM TO DESCRIPTION '
ft. ft.
A - 2581 ft. ft.
NC Well Contractor Certification Number '15:OUTER CASING-(for multi-cased wells)OR LINER.(if ap licable) .
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft. 65.0 ft• 6.0 i" SCH 40 PVC
Company Name
16.INNER.CASING OR TUBING(geothermal closed-loop) - •
2.Well Construction Permit#: -.- FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft• 145.0 ft. 2.0 t"' SCH 40 ' PVC
3.Well Use(check well use): ft. ft. ' in.
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17c SCREEN ':;
Water Supply Well: FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 145.0 ft' 155.0 ft' .2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. •ft. in.
❑Industrial/Commercial ' ❑Residential Water Supply(shared) t8.GROUT ..
❑Irrigation .. ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:. . 3.0 . ft. 125.0 •ft.. AQUA GUARD SLURRY
OMonitoring • ❑Recovery 0.0 ft. 65:0 ft. PORTLAND BENTONITE SLURRY
Injection Well: 0.0 ft. 3,0 ft• CONCRETE. • STICKUP PAD
. ❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
• ❑Aquifer Test • ❑Stormwater Drainage 140.0 ft• 155.0 ft. 20-40 FINE SILICA SAND
• ❑Experimental Technology . ❑Subsidence Control ft. ft. . ..
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING:LOG(attach additional sheets if necessary), `
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
-0.0 ft. 5.0 ft• RED SILTY CLAY
. 4.Date Well(s)Completed: 05/09/23 Well ID# GWA-11 B R S.0 ft. 10.0 ft. BROWN SILTY SAND
• 5a.Well Location: 10.0 ft' 34.5 ft• • TAN SILTY SAND '
BELEWS CREEK:STEAM STATION • 34.5 ft• 58.0 ft.. PWR
Facility/Owner Name Facility IDt'(if applicable) 58.0 ft• 155.0 ft. ROCK
3195 PINE-HALL ROAD BELEWS CREEK 27009 ft. . ft. •
Physical Address,City,and Zip - ft. ft.
STOKES `21.-REMARKS-. • . .. .
BENTONITE SEAL- 125.0-140.0 FEET
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient) 22.Certification:
36° 16' 52.15" N 80° 03' 34.50" W �r--
07/18/23.
6.Is(are)the well(s): IIEPermanent or ❑Temporary Signature of Certified Well Contractor Date
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By signing this form,'hereby certify that the wells)wa ere).const z l c fan ith
7.Is this a repair to an existing well: ❑Yes or INN° ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well n�r MVO-inn St tllst c r' cc pr
If this is a repair,.fill out known well construction information and explain the nature of the of this record has been provided to the well owner. v'
repair under 1121 remarks section or on the back of this form. 202
23.Site diagram or additional well details: '' 9 A
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide addii nal ell•constnt2ti3n info
constntetion,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also a tt`ac�„ j}t rjalrPa es�ifn o,,s {.
drilled: 24.SUBMITTAL INSTRUCTIONS 11 G�e��jajOG
9.Total well depth below land surface: 155.0 _ (ft.)
For multiple wells list all depths if different(example-3 ter 200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
85.82 (R,) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If eater lerel 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
AIR
12.Well construction method: '
24c.For Water Supply and.Open-Loop Geothermal Return.Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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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:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018