GW1-2021-00780_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 FROM TO DESCRIPTION
A - 4121 n. ft.
9 .a, .,5 ` rt. ft.
NC Well Contractor Certification Number �''�
15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION "OIN " FROM TO DIAMETER THICKNESS MATERIAL
Company Name .... _ 0.0 ft- 34.0 ft- 12.0 in .375 CARBON STEEL
_
;` _;,t�1
2.Well Construction Permit#: 16.INNER CASING OR TUBING(geothermal closed-loop)
WR050014_2:•,,,,:,`, ^_�C,% FROM TO DIAMETER THICKNESS MATERIAL
Osi all applicable well construction permits(i.e.L(l a oh)ily, ril9,'Variance,etc) ft. ft. in.
3.Well Use(check well use): \\ R. ft. in.
]7.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public tt. rt. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri at10n ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEM ENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring Recovery rt. ft.
Injection Well:
ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage tr. 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,soil/rock type,grain sim.etc.
0.0 ft• 30.0 ft- PWR
4.Date Well(s)Completed: 09/24/20 Well ID# EX-23 30.0 ft• 220.0 ft. ROCK
5a.Well Location: ft. ft.
ROXBORO STEAM PLANT
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-34.0-220.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
1981999.12 N 994418.07 W '4WA 02/15/21
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this•form,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair.Jill out known well construction information and explain the nature of the of this record has been provided to the we//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 Ovet'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.)
For multiple wells list all depilus ifd�erent(example-3 a 00'and 2@100')10. Submit this GW-1 within 30 days of well completion per the following:
2.74 24a. For All Wells: Original form to Division of Water Resources (DWR),
fwater level is above casing,use"+"Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lJ
11.Borehole diameter: 6.0/10.0/15.0 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method: AIR Program, 1636 MSC,Raleigh,NC 27699-1636
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i..ee.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
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13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018