GW1--04759_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD(GW-1) Fgt.Internal Use Only:
1,Well Contractor Information: -
B RIA N.TH O MAS 14.WATER ZONES
•
Well Contractor Naine FROM TO DESCRIPTION I•'
rt. ft. _
A - 2581
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if up licable) ,
GEOLOGIC EXPLORATION FROM TO' DIAMETER THICKNESS MATERIAL -
0;0_. R. 53.0 ft.- 6.0 '"• SCH 40 PVC
Company Name .16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit 11: - . FROM TO •DIAMETER THICKNESS MATERIAL
l.i.,t all applicable sell consfrutrinn permits(i.e:l i/I Oniony.Stale.Valiance.ale). 0.0 ft: 140•0 f• 2•0 in. SCH 4Q PVC _ .
3.Well Use(check well use): !t. R. in.
Water Supply Well: •'•- 17.SCREEN
FROM TO DIAMETER• "SLAT SIZE THICKNESS •• MATERIAL •
&Agricultural &Municipal/Public. 140.0 fit 150.0 rt. 2.0 1D' 010 SCH 40 PVC
DGeothermal(Heating/Cooling Supply) &Residential Water-Supply(single) - fa R; • in. ' .
llndustrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
[Irrigation . OWells> 100,000 GPD FROM TO 'MATERIAL EMPLACEM ENT METHOD&AMOUNT
• Noii-Wattr Supply Well:' •• 3.0 ft: 120.0, fit. AQUA GUARD. .SLURRY , - - . .
•
°Monitoring °Recovery d.0 rt. 53.0 fir: PORTLANDBEMONITE SLURRY
Injection Well: 0.0 R• fit
3.0 . CONCRETE '' STICKUP PAD -
DAquifer Recharge °Ground+iater.Rernediation
19.'SAND/GRAVEL PACK(if applicable)
&Aquifer Storage and Recovery °Salinity Barrier - FROM • TO . -MATERIAL EMPLACEMENT METHOD , .
&Aquifer Test •OStormwater Drainage 135,0 fit• 150.0, tt. 20-40 FiNE SILICA SAND_
❑Experimental Technology . OSubsidence Control R. .fi. . •
❑Geothermal(Closed Loop) • OTracer ' . 20.•DRILLING LOG(attach additional sheen if necessary)
°Geothermal(Heating/Cooling Return) DOther(explain under 1121 Remarks) FROM TO DESCRIP fION(color,hardness.nntUmek type,grain site.etc.)
0,0 rt' 5.0 fit' RED SILTY CLAY ' . .
' 4.Date Well(s)Completed: 05/1 a/23 Well ID# PMW-b6R(r) S.0 rt•. 10.0: fit.. BROWN SILTY SAND '
• 5a.Well Location: 10.0 -R' 25.0 ft' . TAN SILTY SAND :. .
BELEWS• CREEK STEAM-STATION . 25.0 rt. 46.0 R• PWR .,-
Facility/owner Name Facility I08(if applicable) ' 46.0 f'• 150.0: rt. . ROCK . , .
3195 PINE HALL ROAD BELEWS CREEK 27009 ' •
ft. It
Physical Address.City,and Zip R- ft-
STOKES 21.REMARKS .. . . . - ..
•
• County Parcel Identification No.(PIN) • BENTONITE SEAL:-• 120.0-135.0 FEET •
Sb.Latitude and longitude,in degrees/minutes/seconds or decimal degrees: . .
(if well field,one Iatlong fs sufficient) 22.Certification: '
36° 16' 52.03" N 80° 03' 34.08" w ,,,0w.---
... 07/18/23 :.
6.Is(are)the well(s): l!JPermanent or ❑Temporary Signature of Certified Well Contractor DatePermanent
Bysigithig this form,1 hereby cerOJj'that ihr ell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: &Yes or (°lNo . /SA NC',WON'OUR)or 1SA N(.AC 02C.0200 MI Construction,Starrilards and rimy a copy
!phis is a r/pair•Jill inn known well corn tructiorrJortr ring and erpiaiu the nature of the of lh:.s record has been prnrhed to the well au•eer, f. (' r_•(''� f re
repair under;2/remarks.section or on the hack of this form. !i•r.1�.w iY \ls,,.... '
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 a lrrrlIon4l{o�ve,jl cgg''�l,�u�+}}tion info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also at tlladdljsottal p5L-fi•if necessary
drilled: 24.SUBMITTAL INSTRUCTIONS -r
150-0 Iffflsrrsa:+Cn r rt... I�Urt
9.Total well depth below land surface: . . (ft.) IQ�'-tr
For multiple wells pest all depths iJ'diQiretrt(example.I�'OG'°nrl2@l00'p Submit this GW-1 within 30 days of well completion per he of owing:
10. water level top of casing: 65.03 - (fit) 24a. For.All Wells: Original form.to Division of Water Resources (DWR),
If Statica t is chorerl el below Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I1.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-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary•,cable,direct push,etc.) - county environmental health department of the county where.instatled
FOR WATER SUPPLY WELLS ONLY: •
24d.For Water W Wells producing over 100,000 GPO:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,.NC 27699.161 f
13s,Yield(gpm) ' ' ' Method of test: -
13b.Disinfection type: Amount: • •
•
Form OW-1 North Carolina Department of Environmental Quality.Division of Water Resources 1 I Revised 6-6-?h19'