GW1-2021-00757_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
NICHOLAS HAYES ,9 'Aa+ 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name v :✓
n 1. \ i , ft. ft.
A - 4121
r\ r � ',
ft. fr.
NC Well Contractor Certification Number ��� -,cri'r C)s1 15.OUTER CASING for mulfi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION �i°Cyst^`r 'r� FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft 48.0 ft 12.0 in .375 CARBON STEEL
Company Name ,�>.�sA '\�'��
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W R0500142 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C.County.State,Variance,etc) 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. fr. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fr. ft.
❑Monitoring IN Recovery tr. ft.
Injection Well:
tr. fr.
0Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
OExperimental 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/reck type,grain size,etc.
0.0 ft 1.0 ft. GRAVEL
4.Date Well(s)Completed: 09/02/20 Well ID# EX-41 1.0 ft• 2.0 ft- CONCRETE
5a.Well Location: 2.0 R• 200 "' HARD BROWN SILT
ROXBORO STEAM PLANT 20.0 ft 43.0 ft• PWR
Facility/Owner Name Facility ID#(ifapplicable) 43.0 ft• 220.0 ft• ROCK
1700 DUNNAWAY ROAD SEMORA 27343 ft, ft.
Physical Address,City,and Zip tr. ft.
CASWELL 21.REMARKS
County Parcel Identification No.(PIN) OPEN HOLE-48.0-220.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification-
1980899.32 N 994698.87 W All "A71* 02/15/21
6.Is(are)the well(s)• Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,!hereby certify that the weil(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!9No 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
/J'this it a repair,Jill out known well construction information and explain the nature of the ofthis record has been prorided to the well owner.
repair under#2l 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-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: 220.0 (ft.)
!br nmhiple wells list all depths ifili ferent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 18.69 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
//hater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,INC 27699-1617
11.Borehole diameter: 6.0/10.0/15.0 (in) 24b. For Infection 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 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018