HomeMy WebLinkAboutGW1--07479_Well Construction - GW1_20231120 Run.. . . •
WELL CONSTRUCTION RECORD GW_i por internal use only
1•Well Contractor Information:
Michael Moseley R'Pr'
14.\PATER�To
_ - most"� - R. :
Well Contractor i R. LINE t Dablc
orasimmaimm.
�1lJ for a Certification
is,OITI ER CASING fotri-essed we
r m DIAMETER OAR �"+-
NC Well Contractor CenificationNumber - �pM A R, -
1111111111111
Summit Design & Engineering Services GOR 117BINGRb�1°l elos�
99 9 16.INNER CASIN °1�
2.Well Construction
-
litost R.
IMIIIIa
R.
2.Well Construction Permit#: -� R. wl'sae _
L131all applicable well construction permits(i.e.WC,County,State,Variance,etc) 1L
ER S_-
3.Well Use(check well use): t1'sCREE To IFILSUEZIMII
2 in•
most R
Water Supply Well: It 10 to.❑Agricultural DMunicipaUPublic 15 R 15 R
❑Geothermal(Heating/Cooling Supply) ❑Rcsldcntial Water Supply(single) EMPLACEMENT METHOD&AMOUNT
❑Residential Water Supply(shared) I>!.GROUT ro MATERIAL
°industriallCommcrcial stow 1t• bentonite
°im tion - - IDWells>100,000 GPD 7.1 ..ft. 5.5- 11. �mentlbentanite f,5 bad portland cement/0.5 bag bentonde
Non-Water Supply Well: 5,5 R 0
❑Recovery R, ft,
OMonitoring
Injection Well: ❑GroundwatcrRemediation 19.StNDlGR� f PACK ryiA7E �e ■ ,t c�srl�'rr t rrnldi
❑Aquifer Recharge °Salini Barrier �tON ft• sand
❑Aquifer Storage and Recovery ty 15 R 7.7
pAquifer Test
❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control alnch additional sheets irreeeasa s�eta
2p.DRILLINGLOO DdzscR1pTION lior.haerdn- soiVrocic t... T
(Closed Loop)' ❑Tracer FapM_ TO /
❑Geothetmel iL fa
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks
7/3/2023 LF-PZ-30S R.
Completed: We11I1)# ft.
4.Date Well(s) P
5a.Well Location: f4
Duke Energy Mayo Plant n >c
Facility ID#(if applicable) sL NOV 9 - 7 f l j 3
Facility/OwnerNnme ft. _ - _
1'0660 Boston Rd, Roxboro, NC 27574 R.
Physical Address.City.and Zip 21.REMARKS r.
Person well pad and cover installed
Parcel Identification No.(P11�
County
5b.Latitude and:longitude in degrees/minutes/seconds or decimal degrees: •
22.Certification: :
(if well 5eldone lat/longissufficient)N 78.899430 �_ `AO •
36.538189w ,r`r�/ �'�• 'a3
Signature oCCeni ell Contnictor Date
6.Is(are)the well(s):,l7Permanent or OTemporary Si nl inglh(s form,l heelI ConrNfy char fhe weN(sJ was o(were)constructed in accordance wilt
Yes or ONo
15A NCAG 01C.0100 or 75A NCAC 02C e wel Wefts(wer ucllan Standards and that a copy
7:Is this a repair town existing well: ❑ o rhls record htu been provided to the we!!owner.
- If this is arepair,fill out.known'well construction information and explain the nature of the f
repair under#21 remarks section or on the back of this form 23.Site diagram or additional well details:
8.For Ginn,only
G -I is nClosed-LoopedI
Geothermal Wells having the same add may use the back of this page to provide additional well construction info
Sce Over in Remarks Box).You may also attach additional pages ifnecessary
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells 24 Sl1BM17TAL INSTRUCTIONS
drilled:
(f t') Submit cw-
9.Total well depth below land se era Fa 1P5 9Q2� and 2@lo03 1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent f 24a.For All Wells
13.1 (rL) Original. form to Division of Water Resources (DWR),
10.Static water level'calm below top of casing: information Processing Unit 1617 MSC,Raleigh,NC 27699 lbes
/fwalenlevel is above casing,use""" 24b.For 1 itelion Wells Co to
tq Pro ,1636 sc py DWR,Underground Injection Control(NC),
3:25 f )
11.Borehole diameter:�� MSC,Raleigh,NC 27699-1636
auger 24c.ForW
12.Well construction method: aterS
eye.) count' Water
url nd ODen-Loop Geothermal Return Wells:Copy to the
(i.c.auger,rotary,cable,direct ealthdent of the county where installed
24d.For water
FOR WATER SUPPLY WELD ONLY:' Pe- Wells Droducine over 100 000 GPD•Copy to DWR,CCPCUA
Method of test: _ roam,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gPn1) A1Dount:
•
136.Disinfection types'
North Carolina Department of Environmental Quality �•visiom oC Wahr Resources Form GW-1 • Revised 6 b-201g
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