GW1-2021-00761_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES
Well Contractor Name 1a" �,`'
FROM TO DESCRIPTION
A - 4121 fr. rt.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION ��\` i.i)11 FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft• 35.0 ft- 12.0 in• .375 CARBON STEEL
Company Name 2.Well Construction Permit#: "-..n� ..
'" +' 16.INNER CASING OR TUBING(geothermal closed-loop)
W R050014 i J,y FROM TO DIAMETER THICKNESS MATERIAL
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 fr. R. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) tt. fr. 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: R. ft.
❑Monitoring IN Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Rentediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity 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 necessa
❑Geothermal(Heat ing/CoolingReturn) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain sin,etc.
0.0 ft• 10.0 ft• BACKFILL
4.Date Well(s)Completed: 09/16/20 Well ID# EX-45 10.0 ft• 17.0 ft• BROWN SILT
Sa.Well Location:
17.0 rt' 24.0 fit- PWR
ROXBORO STEAM PLANT 24.0 rL 220.0 ft- ROCK
Facility/Owner Name Facility ID#(if applicable)
rt. ft.
1700 DUNNAWAY ROAD SEMORA 27343 rr. ft.
PhysicalAddress,City,and Zip ft. ft.
CASWELL 21.REMARKS
County Parcel Identification No.(PIN) OPEN HOLE-35.0-220.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification-
1981019.09 N 994571.68 W 1461-� 02/15/21
6.Is(are)the well(s): MPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo I5A NCAC 02C.0/00 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
/(this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under°21 remarks.section or on the back oJ7his 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.)
Gor nuthiple we//s list al/depths tf di/ferent(example-3 r@i 200'and 2 a 100') Submit this CW-1 within 30 days of well completion per the following:
12.74 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
lflroter level is above casing,use"4"
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 of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018