GW1-2021-00791_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES
,F" +: v 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
s`�{ !JfL ft. ft.
A - 4121 y' ,
NC Well Contractor Certification Number t�� J -'=` `'1'
r.,. 15.OUTER CASING for mulficased welts OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICfOVESS MATERIAL
r",•.
0.0 ft- 34.0 ft. 12.0 in .375 CARBON STEEL
Company Name
�+ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W R05001Ai2 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc) f[. ft. in.
3.Well Use(check well use): tr. fr. 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
❑lrrl atlon ❑Wel Is> 100,000 GPD FROM I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. fr.
❑Experimental 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/rock type ritin size,etc.
0.0 ft- 6.0 ft- SOIL-FILL
4.Date Well(s)Completed: 10/20/20 well ID# EX-33 60 tt. 270 ft. PWR
Sa.Well Location:
27.0 ft• 35.0 ft• WEATHERED ROCK
ROXBORO STEAM PLANT 35.0 ft- 280.0 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-34.0-280.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: ��
1982909.23 N 994410.69 W i�G-A715�* 02/15/21
6.Is(are)the well(s): TIPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If 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 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 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: 280.0 (ft.)
For multiple welds list all depths ifdl(fereni(example-3 a 00'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
39•87 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
if water level is above casing,use"+"
]L 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
JT-
(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,IN
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