GW1-2021-01137_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
FROM TO DESCRIPTION
Well Contractor Name 23.5 ft. 39 ft. Wet
4482 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mul6-cased wells OR LINER if a lieable
FRO�11TO
DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. I in.
Compam"Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft• 15 ft- 2 in. sch40 PVC
List all applicable hell permits(i.e.Countr,State, Variance,Injection,etc.)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft' 39 ft- 2 in. .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
❑Irri ation 0 ft. 20 t" Portland Cem Tremie
Non-Water Supply Well:
�
20 r` 22 r` Bentonite Chil Tremie
❑O Monitoring ❑Recoven
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa lieable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
22 r`• 39 r`• #1'Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology El Subsidence Control
20.DRILLING LOG attach additional sheets ifaecess9
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gritin size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 1/18/21 s)Completed: Well ID#WR-24S ft. ft.
ft. ft.
5a.Well Location: ft. ft.
Duke Energy Roxboro Station ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) 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) 3 Bollards
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if'well field.one lat/lone is sufficient)
36.483683 N -79.082195 W
5 nature ofCertitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Qv.signing this Jorm,/herebv ceruft that the u•ell(s) vas(were)consirucied at accordance
r,4 tvrM,15A N('A('02(-.0/00 or IJA AVAC 02C.0200 Well Consiruclion Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo 'iAc��lOq(this record has been provided to the hell ou Pier.
If this is a repair.Jil/out knownwell construction information and ezpl�aindhe t a�i tr�-o)'�1lte+�
"'
repair under:-21 remarks.seclion or on the back q/'Plus Jbrin. i.,) 23.Site diagram or additional well details:
u may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 r LOnstruction details. You may also attach additional pages if necessary.
For multiple injection or non-tracer supply a ehs ONLY with the same cons u- you can
submit one form rD�
. r�-✓ ,S.ft tITTAL INSTUCTIONS
9.Total well depth below land surface: 39 ' `�1iv' •{tt>ffP 1.24a• For All Wells: Submit this form within 30 days of completion of well
hor nmltiple ne/ls list all depths if"different(example-3 m200'and jW11i,) ' construction to the followins:
10.Static water level below top of casing: 23.5 (ft.) Division of Water Resources,Information Processing Unit,
{(crater/ere/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/6 7/8 Auger 24a above, 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(gpm) 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