GW1-2021-00754_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) p_ For Internal Use Only:
1.Well Contractor Information: .�
NICHOLAS HAYES 21 14.WATER ZONES
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Well Contractor Name 1V FROM TO DESCRIPTION
A - 4121
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NC Well Contractor Certification Number �ra� 1 t�;o
�. 15.OUTER CASING for multi-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft• 39.0 ft- 12.0 .375 CARBON STEEL
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WR0500142 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,Stale,Variance,etc.) ft. fr. in.
3.Well Use(check well use): fr. ft. in.
Water Supply Well: 17.SCREEN
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
❑lrri ation ❑Wells>100,000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
OMonitoring (Recovery ft. ft.
Injection Well:
(r. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft. 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 size,etc.
0.0 ft• 3.0 ft• RED CLAY
4.Date Well(s)Completed: 10/02/20 well ID# EX-57 3.0 R. 20.0 ft- BROWN SILT
Sa.Well Location:
20.0 ft' 28.0 ft. PWR
ROXBORO STEAM PLANT 28.0 fr' 530.0 ft. ROCK
Facility/Owner Name Facility ID#(ifapplicable) fr. ft.
1700 DUNNAWAY ROAD SEMORA 27343 ft, ft.
Physical Address,City,and Zip ft. ft.
CASWELL 21.REMARKS -
County Parcel Identification No.(PIN) OPEN HOLE- 39.0-530.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal:degrees:
(if well field,one lat/long is sufficient) 22.Certification: /,�i
1983524.75 N 993999.87 W 141I " 7� 02/15/21
6.Is(are)the well(s): hJPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance widr
7.Is this a repair to an existing well: ❑Yes or 15No 15A NCAC 02C.0/00 or I5A NCAC 02C.0200 Well Construction Standards and that a cony
/f this is a repair,Jill out known well construction information and explain the nature of the of this record has been provided to the we//owner.
repair under#21 remarks section or on the back of this form.
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 530.0 (ft.)
/•or nudtiple wells list all depths ifdiereni(example-3 r@r 200'and 2 100') Submit this GW-1 within 30 days of well completion per the following:
43.78 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lj'waier level is above casing,use"I"
11.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 27699-1 6 1 1
13b.Disinfection type: Amount:
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018