GW1-2021-00785_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES �, 14.WATER ZONES
s , ., FROM TO DESCRIPTION
Well Contractor Name ��, tt. ft.
A - 4121 , z ��\
7 1 ft. ft.
NC Well Contractor Certification Number a �';s;
15.OUTER CASING.for mulfi-casedwells OR LINER if a licable
GEOLOGIC EXPLORATION \��N� t r FROM TO DIAMETER THICIaVESS MATERIAL
r 0.0 ft. 29.0 ft• 12.0 i" 375 CARBON STEEL
Company Name ry r�i� JJ :;ti
W R05001 ;,, Y .` 16.INNER CASING OR TUBING"eothermal closed-loop)
2.Well Construction Permit#: V'i FROM TO DIAMETER THICKNESS I 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.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring Recovery 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 u. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
e
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock e, nin size, tc.
0.0 It. 24.0 ft. PWR
4.Date Well(s)Completed: 10/23/20 Well ID# EX-28 24.0 ft. 280.0 ft. ROCK
Sa.Well Location: ft. ft.
ROXBORO STEAM PLANT ft. ft.
Facility/Owner Name Facility ID#(if applicable)
1700 DUNNAWAY ROAD SEMORA 27343
Physical Address,City,and Zip ft. ft.
CASWELL 21.REMARKS
County Parcel Identification No.(PIN) OPEN HOLE-29.0-280.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: "
1982627.05 N 994253.94 W lel- 02/15/21
6.Is(are)the well(s): RPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certt&that the wells)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or (ENo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of die 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 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.)
For multiple sells list all depths ifdii ereni(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
45.8 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
1f water 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 GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018