GW1-2021-00771_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 Wig,,� �� o O, �Ot) FROM TO DESCRIPTION
ft.
A - 4121 �r\t��� `� '� ' ft. ft.
NC Well Contractor Certification Number v r
)1.5.OUTER CASING for mulfi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION Y � �_� FROM TO DIAMETER THICKNESS MATERIAL
"ss 0.0 rr• 44.0 ft- 12.0 In• .375 CARBON STEEL
Company Name y;a _ _ "
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WR0500142 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri atlon ❑Wei I s>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring [ERecovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa 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) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilhnck type,grain sin,etc.
0.0 rt• 40.0 rt• PWR
4.Date Well(s)Completed: 10/12/20 Well ID# EX-36 40.0 a• 280.0 rt• ROCK
5a.Well Location: ft. ft.
ROXBORO STEAM PLANT ft. ft.
Facility/Owner Name Facility 1D#(if applicable)
ft. ft.
1700 DUNNAWAY ROAD SEMORA 27343
Physical Address,City,and Zip
ft. ft.
CASWELL 21.REMARKS
County Parcel Identification No.(PIN) OPEN HOLE-44.0-280.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
1983125.80 N 994276.54 W � 02/15/21
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
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
/J'this is a repair,fill out known ivell construction inJbrmalion and explain the nature of the of this record has been provided to the well owner.
repair under 4121 remarks section or on the back of lhis 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.)
Far multiple wells list all depths iftli ferem(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
50.3 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
lJlroter 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 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