GW1-2021-00784_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. �`? 'sr- FROM TO DESCRIPTION
ft. ft.
A - 4121
NC Well Contractor Certification Number h� X .
,1S.OUTER CASING for multi-cased wells OR LINER tf a licable
GEOLOGIC EXPLORATION Ca�N FROM TO DIAMETER THICKNESS MATERIAL
n r4J-;t 0.0
Company Name fr 46.0 tr 12.0 '" 375 CARBON STEEL
16., C r1,,` i -- -
2.Well Construction Permit#:
WR0500142 ,%!`ids ` FROM TO
CASING OR TUBINGDIAMETERhe THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO .DIAMETER SLOT SIZE _THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring NRecovery R. 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 ❑Stonnwater 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 921 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 fr. 27.0 tt. PWR
4.Date Well(s)Completed: 10/26/20 well ID# EX-27 27.0 R• 35.0 tt• ROCK
5a.Well Location: 35.0 ft 45.0 fr' WEATHERED ROCK
ROXBORO STEAM PLANT 45.0 tr• 280.0 rr' 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 21.REMARKS
County Parcel Identification No.(PIN) OPEN HOLE-46.0-280.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
1982562.72 N 994451.11 W 14WA7%i 02/15/21
6.Is(are)the well(s): I!gPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this firm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!5No 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If ih/s is a repair,fill out known well consiruction information and explain the nature of dte qJ 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 1 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.)
Por muhiple wells list all depths ifdifjerent(example-3 a 200'and 1 ref 100') Submit this GW-1 within 30 days of well completion per the following:
65.0 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
//hater lerel 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 GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018