GW1-2021-00763_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES
^ '��'n o���� 14.WATER ZONES
Well Contractor Name 4�,,.�� FROM ft To ft. DESCRIPTION
NC Well Contractor Certification Number 't�" ,�\ .,^ 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION `� ^�,.;i.''FROM it TO ft-
DIAMETER to THICKNESS MATERIAL
�`;�•- 0.0 54.0 12.0 .375 CARBON STEEL
Company Name
4 a' 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:
WR0500142 ��'*~V FROM TO DIAMETER THICKNESS MATERIAL
a'a�
List all applicable well construction pernins(i.e.U1C,County,State, ariance,etc) ft. ft. in.
3.Well Use(check well use): rt. tr. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural ❑Municipal/Public ft. fr. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Uri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
OMonitoring 05Recovery ft. fr.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑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,soil/mck e, rain size,etc.
0.0 ft 6.0 rt BROWN CLAY
4.Date Well(s)Completed: 08/29/20 Well ID# EX-47 6.0 fr. 20.0 e. HARD BROWN SILT
Sa.Well Location:
20.0 ir. 30.0 rt. PWR
ROXBORO STEAM PLANT 30.0 ft 42.0 rt WEATHERED ROCK
Facility/Owner Name Facility ID#(if applicable) 42.0 ft' 220.0 rr' ROCK
1700 DUNNAWAY ROAD SEMORA 27343
Physical Address,City,and Zip ft. ft.
CASWELL 21.REMARKS,
CountyParcel Identification No.(PIN) OPEN HOLE _54.0-220.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification-
1981181.14 N 994583.53 W 02/15/21
6.ls(are)the well(s): OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the icel/(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NC'AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a cap),
if this is a repair,fill out known melt construction information and explain the nature of the gf1his record has been provided to the well owner.
repair under`i21 remarks section or on the back gl'this firm.
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-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.)
1;or multiple wells list al/depths ifdiiferent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
2•95 24a. For All Wells: Original forth to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f water level is above casing,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 of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producins over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018