GW1-2021-01136_Well Construction - GW1_20210215

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
James Robertson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 25 ft- 35 ft. Wet
4482 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a bitable A
FROM TO DIAMETER TTHCKNESS MATERIAL
Parratt-Wolff, Inc. ft. I
ft. in.
Company Name 16.INNER CASING OR TUBING. geothermal closed-loop -
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 20 ft. 2 in. sch40 pVC
List all applicable hell permits(i.e.C'ountr,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 f`' 35 ft. 2 'n .010 SCh40 PVC
ft.❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 16 ft. Portland Cem Tremie
Non-Water Supply Well:
16 ft- 18 ft- Bentonite Chii Tremie
ZMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL'PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
18 35 #1 Sand Tremie
❑Aquifer Test , ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rack type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
Date Well 1/18/21 WR-23S s)Completed: Well ID# 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 4 PC
County Parcel Identification No.(PIN) Pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Iaulong is sufficient) ^
36.483685 N -79.081956 W
5 nature of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary
BY signijg,4his,Jorm, 1 herehv cerlift that the well(s)was(here)constructed in accordance
u obrl+'3'AY(aflC 02C'.0100 or 15A NC'AG 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or El No _. I.,t' 1 a/�t�ntl hecord has been proridec/to the ire//owner.
/f this is a repair,Jill out known well construction information and explain the naturV�a.f 11 "','i
repair ender=21 remarks section or on the back of'thi.s Dorm. N• A 23.Site agram or additional well details:
`►�' YOU Ise the back of this page to provide additional well site details or well
8.Number of wells constructed 1 r A,.c`f'st5vction dqt iIdffi�You may also attach additional pages if necessary.
I•or multiple injection or non-trater.supph,wells ONLY erith the same construction,s�h)s 1,,�)
submit one Jorm. $UW,vIff INSTUCTIONS
9.Total well depth below land surface: 35 .r,.;(ft ;;� 4(e-for All Wells: Submit this form within 30 days of completion of well
For nuthiple ire//s list all depths it different(example-3@200'and 2 n l00') 1 r' ` " construction to the following:
10.Static water level below top of casing: 25 (ft-) Division of Water Resources,Information Processing Unit,
/•j'irater level is above casing,use'•-- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Iniection 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
m 13a.Yield
(gP ) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013