GW1-2021-00755_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES r„� ��',�8��` 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name °� Il\ ft. ft.
A - 4121 `�",
ft. tt.
NC Well Contractor CertificationNumber
15.OUTER CASING for multi-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION n,el �.^ t.�r i!fj11 FROM TO DIAMETER THICKNESS MATERIAL
Company Name 'a
0.0 ft. 1 20.0 ft- 12.0 .375 CARBON STEEL
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W R0500142 FROM TO DIAMETER THICKNESS MATERIAL
Li.sl all applicable ire//construction pernius(i.e.UIC,County,Stale,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
ppy FROM TO DIAMETER SLOT SIZE 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 ORecovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater 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 e, imin size,etc.
0.0 ft• 2.0 ft. RED CLAY
4.Date Well(s)Completed: 10/01/20 Well]D# EX-58 2.0 ft• 14.0 ft• PWR
Sa.Well Location:
14.0 ft• 531.0 ft' ROCK
ROXBORO STEAM PLANT ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. 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- 20.0-531.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certification- /��C� �A
1983553.73 N 993948.06 W /it/f 02/15/21
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the hell(.)was(were)constructed in accordance wilh
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 copy
Iflhis is a repair,Jill out known ire/l construction information and explain the nature ofihe of'this record has been provided to the hell oirner.
repair under#21 remarks section or on the back offlus 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 I GW-I 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: 531.0 (ftJ
For multiple use/is/is/all depths tfdifferenl(example-3@200'and 2 n 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 51.19 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
1 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
pater level is shore casing,use op
11.Borehole diameter: 6.0/10.0/1 5.0 (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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018