GW1--07480_Well Construction - GW1_20231120

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WELL C'"NSTRUCTION R tonal Use Only
1•Well Contractor ECO
Info RD Gw-1 Fain
MiCh lmation;
eel Mosel N>s ;;;0000.00.0vai
Well Contractor
o•_ .r Name' e� 14.WATER�j0 p.,�'•L��Lt\"" °\� ef3 FROM
`�� mole
/ R• LINER tfa tlMATERIAL
NC Well Contractor Certification
p G for
ORICKNESS
eniGcation Number OUTER
CASING DIAMETER
Summit Design & En 1�
Company Name gineering Services taunt11.
CASINGORTUBINGE7>�h0To
r`O'TRICESS
DIAM 1111111111111.111
2.Well 16.INNER TO n COR9traeti°n Pe FRO'I
List all applicablermit#;
well construction ft. _
permits(i.e.UIC,County,Staie,Variance,etc) f6 •FII,- MA-
3•Well Use(check well use): ETER SLOT SUE Water Supply 17.SCREEN
ro DIAM
PP Y Well: in. -
n.
mom n• 2
❑Agricultural to 15.4 is
❑Municipal/Public 25.4
❑Geothermal(Heating/Cooling Supply) ❑R 1 (single) tt' 25'4 EMPLACEMENT M OD&AMOUNT
Residential Water Supply
❑IndustriaVCommercial ❑Residential Water Supply( MA1EfWl
1 (shared) Is,GROUT TO fa bentonite
❑l[TI BtiOR FROM1t
Non-Water Supply Well: ❑Wells>100 OOO GPD 12 7 fa 10 ft �menUbentonite 1.5 ba0 Portland cement/0.5 bag bentonite
InMction ing It. 0 ,
Injection Well: ❑Recovery _- 10 (4 I°
Ii❑Aquifer Recharge p. da••liable EMPLACEMENT METHOD '
❑Ground tq,SAND/GRAVEL PACK ' :f
water Remedialion MAT•uceb•
❑Aquifer Storage and Recovery FROM TO
❑Salinity Barrier n• sand
❑Aquifer Test 25.4 It 12.7
❑Stonnwater DrainageR•
❑Experimental Technology ❑SubsidenceConVol fL
❑Geothermal(Closed Loop) DCRIp'fION color hardnm.eoiUrock ty,rain etc.
❑Tracer 20.DRILLING LOG attach additional sbeed ff necasa ,.;'
FR051 7'O lr
❑Geothermal(Heating/Cooling Retum OOltter(ex lain under#2l Remarks) ft. p
4.Date Well(s)Completed: 7/5/2023 LF-PZ-35S ft. ft. 'f,
�_WelllD# ft. k!
5a.Well Location: ft. • > }
Duke Energy Mayo Plant ft.
ft. OV A ? 90
{ Facility/Owner Name Facility ID!!(if applicable) ft.
10660 Boston Rd, Roxboro, NC 27574 ft.
Physical Address,City,and Zip ft. Ft.
1 Person 21.REMARKS
well pad and cover installed
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient) 22.Certification:
36.539332 N 78.897922 W i,'`' -_?F-.2 1
Signature of Certified Contractor Date
CertifiedI 6.Is(are)the well(s): OPermanent or OTemporary fly signing this form.l hereby cert that the well(s)was(were)constructed in accordance with
01
I f SAth NCACisrecord 01C has.0100been or 15Aprovided NCACtothe 02Cu'efl.02ow00 We!!Construction Standards and that a copy
I 7.Is this a repair to an existing well: l7 or ONo ner.
If this is a repair,fill out known well construction information and explain the nature of the
repair tinder anremarks section or on the back of this orm.
23.Site diagram or additional well details:
Geothermal Wells Navin the same You may use the back of this page to provide additional well construction info
g (add'See Ovel in Remarks Box),You may also attach additional pages if necessary.
8.For GeoprobeiDPT or Closed-LooIndicate TOTAL NUMBER of wells
construction,only 1 GW-1 is needed. 24,SUBMITTAL INSTRUCTIONS
drilled: [} (ft.)
j 9.Total well depth below land surface a Pie•3Q2
00'and 1t✓loo') Submit this GW-1 within 30 days •of well completion per the following:
For multiple wells list all depths ifd�ereni( 7 24a. For All Wells
tit') �• Original form to Division of Water Resources (DWR),
10.Static water Icvel below top
°fcasiag: 2 Information processing Unit,1617 MSC,Raleigh,NC 27699-1617
program,For I1 ection Wells:Copy to DWR,Underground Injection Control(IUC)
!f wafer level is above'casirrg3 25 (in.) gram,1636 MSC,
Raleigh NC 27699-1636
11.Borehole diameter:g 24c.For Water Sunn
method: county environmental and Open Loop Geothermal Return Wells:Copy to the
12.Well construction etc.) ""mot Health department of the county where installed
auger,rotary•cable,direct push, 24d.For Water
(i.e.aug V YELLS ONLY: Permit Prngran, 611Is roducin over 100 000 GPD•Copy to DWR,CCPCUA
FOR WATER SUPPLY Method of test: MSC,Raleigh NC 27699-1611
Amoupt:
13a.yield(gPln)
{ 13b Disinfection type' Department of Environmental Quali
North'Carolina Dep " Division
of tiyater Rosource$ Revised 6-6-201 s
Form GW-1
I