GW1-2021-00758_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: •. �{
NICHOLAS HAYES °'�'�
^"w, 0 14.WATER ZONES `
Well Contractor Name ,�y„� FROM TO DESCRIPTION
A - 4121 ' 0 fr. ft.
�.'� n� �:a''' ft. tt.
NC Well Contractor Certification Number ( (1
pp� s✓ 15-OUTER CASING for multi-cased wells OR LINER if a licable
_,r- 1 FROM TO DIAMETER THICKNESS MATERIAL
GEOLOGIC EXPLORATION :
0.0 ft 53.0 ft.
12.0 in .375 CARBON STEEL
Company Name _
W R0500 �� 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): fr. 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 atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ORecovery 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
❑Experimental Technology ❑Subsidence Control
❑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,soi tivck type, min size,etc.
0.0 ft• 2 0 ft• GRAVEL
4.Date Well(s)Completed: 09/03/20 Well ID# EX-42 2.0 ft' 3 0 fL CONCRETE
Sa.Well Location:
3.0 ft' 17.0 fr' BROWN CLAYEY SILT
ROXBORO STEAM PLANT 17.0 rr. 28.0 ft' HARD BROWN SILT
Facility/Owner Name Facility ID#(ifapplicable) 28.0 rL 47.0 It- PWR
1700 DUNNAWAY ROAD SEMORA 27343 47.0 ft- 220.0 tt• ROCK
Physical Address,City,and Zip ft. ft.
CASWELL 21.REMARKS
County Parcel Identification No.(PIN) OPEN HOLE 53.0 220.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certification:
1980923.58 N 994663.29 W � 02/15/21
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
IJ'this is a repair,Jill out known well construction in%rntation and explain the nature of the of this record has been provided to the well owner.
repair under 421 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: 220.0 (ft.)
For multiple wells list all depths ii(Wi ferent(example-3 r(�t 200'and 2@100') Submit this GW-]within 30 days of well completion per the following:
17.32 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
ljwaler level is above casing,use"+"
11.Borehole diameter: 6.0/1 0.0/1 5.O (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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018