GW1--05569_Well Construction - GW1_20240913

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i .
1.Well Contractor Information:
Eddie Thomas (Brian)
la.WATER ZONES � )
. Well.Contractor Name FROM TO DESCRIPTION
ft. • ft.
• 25$1-Q ' ft.t rt. I
NC-Well Contractor Certification Number. i ; 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Geologic Exploration, Inc. FROM ' TO .DIAMETER THICKNESS MATERIAL
' ft ft: 11 in
Company Name
. •16.INNER CASING OR TUBING(geothermal closed-loop)
_ • 2.Well Construction Permit#:. - • FROM- . 'TO •DIAMETER'. THICKNESS' ' MATERIAL ' ,
List all applicable'irell construction permits(lb.U/C County,State.Variance,etc) 0.0 ft 1,38:01 ft.• 2 '• i', in' ' SCH.40 PVC • •
3.Well Use'(cheek well use):, 158:0 ft 163.3 ft-, 2' , in. .SCH 40 PVC
/ 17.SCREEN •
Water Supply WcIL`• . FROM TO ''DIAMETER. SLOT SIZE . THICKNESS' MATERIAL
❑Agrictilturat ❑Municipal/Public 138.0 I`' .158.0;ft• 2 t"' ; 0.010 inch SCH 40 PVC .
❑Geothermal(Heating/Cooling Supply)'',, ❑Residential•Water Supply(single) ft•, ft. in;i
❑Industrial/Commercial °Residential Water Supply(shared) 18,GROUT' 'r
. ❑Irrigation .. . ❑Wells>100,000 GPD 'FROM' TO-•' MATERIAL ' EMPLACEMENT METHOD&AMOUNT. ' . .
Non-Water Supply Well: 0:0 ft- 127:7 ft. Portland Bentonite Tremie
• CJMonitoring. DRecovery ft. • ft. -
•
Injection Well:
❑Aquifer Recharge - ❑Groundwater Remediation •
ft. ft.' �'
19.SAND/GRAVEL PACK.(if applicable).
❑Aquifer-Storage and,Recovery ❑Salinity Barrier . FROM : ' '•TO, :: D'MATERIAL' . " EMPLACEMENT METHO ', "+( '
❑Agutfer;Test ❑Stormwater Drainage,, 133.4 ft , 135:2 ft, 'SecondaryFilter(GP#1) Gravity/POUT '
'' ❑Experimental Technology ❑Subsidence Control 135 22 ft 164'.,1 ft.;, Pnmary Filter(GP#2) Gravity/Pour '•
•
❑Geothermal(Closed Loop) , ❑Tracer • 20.DRILLING LOG(attach additional sheets if necessary) ' '
. •' ",FROM:,.. TO - ,:DES,., (color,hardness,soil/rock type;gram she.etc.) '
• ❑Geothermal(Heating/Cooling Return) . ❑Other(explain under#21 Remarks), ;:.• '
0 ft- 2 ft- Red Lean•Clay - •
4 Date Wells)Completed, 08/1 ',...• - Well ID# DW:12 2 •ft• • 8 for Red Brown Sandy Si '
' ' Sa:•Well Location• 8 .ft' • 16 , ft Yellow Red'Brown•Silty Sand '
'•BeleWs•Creek Steam Station 16 ft• '34 f`. Yellow Red.Brown Sandy Slit
Facility/Owner Name. - Facility ID#(if applicable) ' ' 34- it• 164.1 f`- Rock Schist/Gneiss r-• r ,, '
t+
3195 Pine Hall Road, Belews Creek,.NC'27009 ft ft. ` L_3•. 9'z Li
Physical Address;City and Zip' ft., :. ft. . I! SEP• 1• S; LOr-4,
:: Stokes
,
•
County Parcel Identification No•(PIN) r'- .y UPtil
2l REMAR
BENTONITE SEA 127.7 to 13p;t#, i ,-, r
' ,..•Dnlling.Log Depths(Except Termination)Approximated to R'�a 'koDt '
a. Sb.Latitude arid longitude in'degrees/minutes/seconds or decim�il degrees: • - ,
• (if well field,one•lat/lonb is sufficient) 22 Certification', I;' '
36:2610, N 80 0623 w j, �� • '
Signature of certified
6.Is(are)the'well•(s): 'CIPermanent 'or ❑Temporary fied Well Contactor. •ar , • Date,.,
Bysrgningtlusforin;/hereby Geri that(lie nell(s)n as(n ere)constructed in accordance ii it/i•
7 Is•this a repair to'an existing well ' ❑Yes or CINo' - /5A NGAC 02C.':0/00 of/SA NCAC 0'C.0200 Well Construction Standards and that a copy
If this is a repair;fill out knotyn well construction it formation and explain the nature'of the of this record has been provided to the yell owner.
. repair under 1121 remarks section'or on the back of ibis form. ' I.
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.tot provide additional well construction info
' (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
consfruction,only I GW-1 i's;needed. Indicate TOTAL NUMBER of wells ,•
drilled:i• 24.SUBMITTAL INSTRUCTIONS+i
1.64.1 •
9.Total well depth below land surface (ft.) Submit this GW-1 within 30 days of Well completion per the following:
For multiple wells list all depths if-different ferent(exa»nple-3@200•and 2@100') .
10.Stotie water level top of casing: 1.55.2- • (ft,) .24a.•For.All.Wells .Original form'.to+Division'of Water'Resources (DWR),
110 St level is above el belowihg,us o "• Information.Processing Unit, 1617 MSC,Raleigh,NC 27699-1617 .
a nominal(0-40 It) 24b.For.Injectiori,Wells: Copy to'DWR,-Underground Injection.Control(IUC)
11,Borehole diameter: 6.5 nominal(40-164.1 III .'(in:) Program,]fish MSC,Raleigh,NC 27699;1636 '
• 1. Well eDnstrnetioq method: Down The'Hole (DTH) Hammer • •i` - - • •' • • - , lR.
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 ofthe county where installed' ,
FOR WATER SUPPLY4EL1.S ONLY: •• • 24a.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
- Peimit Program;161-1 MSC,Raleigh,NC 27699-1611, • . ..
13a.Yield(gpm) Method of test: .
13b.Disinfection type: Amount: _ .
,..r':.• 'FoinOW-I-• '' ..; With CaiolinaDepiirtmentofEnvironneiital,Qualiy-Divisionof Water Resources•' Revised6,6-20(S
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