GW1-2021-00756_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES -��m' n 7��� 14.WATER ZONES
Well Contractor Name ft.
•.F OM TO DESCRIPTION
A - 4121
NC Well Contractor Certification Number 15.OUTER CASING for tnulfi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0.0 ft. 28.0 ft- 12.0 i" .375 CARBON STEEL
- -
W R0500142 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(i.e.U/C,County,State,Variance,elc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: 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
❑lrri ation ❑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
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
❑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,soi0rnck type,grain size,etc.
0.0 ft. 8.0 ft. PWR
4.Date Well(s)Completed: 09/30/20 well iD# EX-59 8.0 ft. 10.0 ft. ROCK
5a.Well Location: 10.0 ft' 20.0 ft' PWR
ROXBORO STEAM PLANT 20.0 ft. 536.0 ft• ROCK
Facility/Owner Name Facility ID#(ifapplicable) 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 28.0 536.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: ,�e
1983585.53 N 993890.91 W �'" 02/15/21
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing This form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,Jill out known ivell construction information and explain the nature of the of this record has been provided to the well owner.
repair under 921 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 Ovet in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 536.0 (ft.)
For multiple wells list all depths ifdiJjerent(example-3 ti 00'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
55.17 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f rraier level is above coring,use"+"
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-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department ofthe 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 G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018