GW1-2021-00759_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: -,
NICHOLAS HAYES 1a.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
f'��;'' � y
ft. ft.
NC Well Contractor Certification Number `�
C*' -15.OUTER CASING for multA-ased wells OR LINER if a 'licable
GEOLOGIC EXPLORATION ^ /�'ri.ti), FROM TO DIAMETER THICKNESS MATERIAL
('ti 0.0 ft. 1 53.0 fit- 12.0 in .375 CARBON STEEL
Company Name
W R050014t'P FROM16. TO
CASING OR TU DING(Reo hermal 'C closed-loop) MATERIAL
2.Well Construction Permit#: ^g.
List all applicable well construction permits(i.e.UIC,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 rt. tr• in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. h. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring 29Recovery fr. ft.
Injection Well:
ft. ft.
OAquifer Recharge ❑Groundwater Remediation - -
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
0.0 ft- 20.0 ft- BACKFILL
4.Date Well(s)Completed: 09/14/20 Well ID# EX-43 20.0 ft• 35.0 ft' HARD BROWN SILT
5a.Well Location: 35.0 it' 47.0 it' PWR
ROXBORO STEAM PLANT 47.0 ft- 220.0 ft- ROCK
Facility/Owner Name Facility ID#(ifapplicable) it. 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 53.0-220.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hit/long is sufficient) 22.Certification:
1980944.90 N 994628.35 W 02/15/21
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
Hy signing this form,/hereby certify that the well(s)was(were)constructed in accordance widt
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1/'dus is a repair,Jill out known well construction information and explain the nature of the oJ7his record has been provided to the well owner.
repair under 921 remarks section or on the back q('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: 220.0 (ft.)
kar multiple wells list all depths J'diJjerent(example-3 0 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 16.4 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
if water level is above casing,use"+
Information Processing Unit,1617 MSC,Raleigh,NC 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 G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018