GW1-2021-01135_Well Construction - GW1_20210215

WELL CONSTRUCTION RECORD For Internal use ONLY.
This form can be used for single or multiple wells
I.Well Contractor Information:
,James Robertson 14.WATER ZONES l
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4482 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING G formultf-cased wells OR]LINER.ifa licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. rr. ft. in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-log
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 25 ft. 2 in' Sch40 PVC
List all applicable hell permits(i.e.Couniv,State, Variance,Injection,etc.)
ft. I ft. in.
3.Well Use(check well use): -17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25 ft' 35 ft- 2 1n- .010 Sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 fr. 20 ft. Portland Cem Tremie
Non-Water Supply Well:
Monitoring ❑Recovero 20 fL 23 ft Bentonite Chi Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier It. ft.
23 35 #1'Sand Tremie
❑Aquifer Test ❑Stormw'ater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 1/18/21 s)Completed: Well ID#W R-22 S ft. ft.
ft. ft.
5a.Well Location:
Duke Energy Roxboro Station
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1700 Dunnaway Road, Semora, NC 27343 ft. ft.
Physical Address,City,and Zip 21.REMARKS. '
Person 8 FMC
County Parcel Identification No.(PIN) Pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one[at/long is sufficient)
36.483497 N -79.082109 w ' ' .Zd .z
Si 3ture ofCertifted Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
signing t/uis.fornt, /hereby cerlifi%that the we/l(s) was(were)constructed in accordance
�,ith 1.5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that o
7.Is this a repair to an existing well: ❑Yes or E]No zy'• 1 copy q/this record has been provided to the hell owner.
l/this is a repair,fill out known well construction in/ormalion and explp W�t emit;'Dfthe
repair under 721 remarks section or on the back of this farm. °$ tl 3.Site diagram or additional well details:
L�ou T43
vse the back of[his page to provide additional well site details or well
8.Number of wells constructed: 1 J r�,�r "Rion details. You may also attach additional pages if necessary.
For multiple inlectiou or non-seater supply w ells ONLY with the same can.•t •tnm,you can pr,%�
submit one Jorm. `;✓``'r�,{3 UBMITTAL INSTUCTIONS
kiQ�s c o-
9.Total well depth below land surface: 35 •r`;'�"� =;'�~eft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi#/rent(example-3C200'and '/00') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
I/water level is above caving,use- • 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
8 1/4 HSA 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY"WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection;Wells:
(gP ) Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department ol'Ens,nonntent and Natural Resources-Division of Water Resources Revised August 2013