GW1-2021-00705_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) 5P4_1Rt bd_1'SlseYOnly:
1.Well Contractor Information: J V-1
NICHOLAS HAYES @v1 a. A ER ZONES
Well Contractor Name FROM O . 1 it DESCRIPTION
,;1QI1 frt ; fr.
A - 4121 I�"mil' wo
u, ar ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0.0 ft. 49.0 ft 12.0 in. 1 .375 CARBON STEEL
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W R0500142 FROM TO DIAMETER I THICKNESS MATERIAL
List al/applicable well construction permits(i.e.U/C,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring Recovery ft. ft.
Injection Well:
H. R.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fr. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain siu,etc.
0.0 it. 12.0 " BROWN SILT
4.Date Well(s)Completed: 10/08/20 well ID# EX-56 120 ft. 280 ft. pWR
5a.Well Location: 28.0 ft' 44.0 it' WEATHERED ROCK
ROXBORO STEAM PLANT 44.0 ft 522.0 ft. ROCK
Facility/Owner Name Facility ID/1(if applicable)
ir. fr.
1700 DUNNAWAY ROAD SEMORA 27343 it. ft.
Physical Address,City,and Zip ft. ft.
CASWELL 21.REMARKS
County Parcel Identification No.(PIN) OPEN HOLE-49.0-522.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification-
1983491.98 N 994055.65 W i/W// AV� 02/15/21
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a caw
lfthis•is a repair,Jill out known well construction information and explain the nature ofthe of this record has been provided to the we//owner.
repair under 921 remarks section or on lire back of this farm.
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 additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovet in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 522.0 (ft.)
For nudtiple wells list all deptu tfd�erent(example-3 a 200'and 2@/00') Submit this GW-1 within 30 days of well completion per the following:
35.96 24a. For All Wells: Original form to Division of Water Resources (DWR),
/f
J Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
water level is above caring,use"+"
II.Borehole diameter: 6.0/10.0/15.0 (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-Loon Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018