GW1-2022-05624_Well Construction - GW1_20220610

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A - 2581
It. ft. j
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased-wells OR LINER if a ticable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. i in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loot))
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft' 230.0 ft- 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: M SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 230.0 ft' 250.0 ft. 2.0 in- .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. I ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells> 100,000GPD FROM TO MATERIAL- EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 200.0 IL PORTLANDaENTONITE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 227.0 ft- 264.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology []Subsidence Control rt. 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,soillmck type,prain size,etc.
0.0 ft. 12.0 ft- BROWN SILTY SAND
4.Date Well(s)Completed: 05/13/22 well ID# PMW-03D 12.0 n- 15.0 It- PWR
5a.Well Location: 15.0 ft. 264.0 ft' C3CK g
ROXBORO STEAM PLANT ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 2077
1700 DUNNAWAY ROAD SEMORA 27343 ft. ft.
Physical Address,City,and Zip ft. ft. IflfOriviiea0 1`Pic^r ry
rig
PERSON 21.REMARKS '
County Parcel Identification No.(PIN)
BENTONITE SEAL-200.0-227.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certification:
360 28' 54.09" N 790 04' 12.08" W 06/02/22
6.Is(are)the well(s): (EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this torn,i hereby certify that the'well(s)was(here)constructed in accordance uriih
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction inlibrnmtion and explain the nature of the of this record has been provided to the well owner.
repair under 1:21 remarks.section or on the back oJ'this Jorni.
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: 250.0 (ft '
For multiple wells list all depths ifdiJferent(example-J ct 200'and 2@1001 ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 155.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.0 (in.) 24b. For Infection 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 Ramp Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) Method of test: k
I
13b.Disinfection type: Amount: j
i
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018