GW1-2021-00781_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: \
NICHOLAS HAYES "g° 14.WATER ZONES
Well Contractor Name S' FROM TO DESCRIPTION
A - 4121 '�, - ft. rt.
J " ft. ft.
NC Well Contractor Certification Number v 15.OUTER CASING for multi-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION ' °' � FROM TO DIAMETER THICKNESS MATERIAL
Company Name �,+'i ,'•. V; , 0.0 ft• 43.5 ft. 12.0 i" .375 CARBON STEEL
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W R0500142 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ire//construction permits(i.e.VIC,Coumy,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
❑Irrl ation ❑Wells>100,000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑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 I TO DESCRIPTION color,hardness,soillrock type,grain sin,etc.
0.0 ft. 10.0 ft. PWR
4.Date Well(s)Completed: 1 0/22/20 Well ID# EX-24 10.0 ft. 17.0 ft- ROCK
5a.Well Location: 17.0 ft' 44.5 ft' PWR
ROXBORO STEAM PLANT 44.5 a• 280.0 fr• ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1700 DUNNAWAY ROAD SEMORA 27343 ft. ft.
Physical Address,City,and Zip ft. ft.
CASWELL 2L REMARKS
County Parcel Identification No.(PIN) OPEN HOLE-43.5-280.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
1982709.12 N 994507.38 W 02/15/21
6.Is(are)the well(s)• MPermanent or ❑Temporary Signature of Certified Well Contractor Date
lay 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 MNo I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1flhis is a repair,fill out known me//construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under 121 remarks section or on the back of this fornn.
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 wells list all depths ifdiffereni(example-3 c@200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
37.7 24a. For All Wells: Original form to Division of Water Resources (DWR),
]0.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/fwater level is above casing,use"+"
11.Borehole diameter: 6.0/10.0/15.0 (i") 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 GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018