GW1-2021-00765_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: P,�,•
NICHOLAS HAYES 'i� ��/' 14.WATER ZONES
Well Contractor Name -" t� rC
FROM TO DESCRIPTION
to
A -
A - 4121 b �
NC Well Contractor Certification Number \J�ta �;•j: 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION fi<,;. FROM TO DIAMETER THICKNESS MATERIAL
A" 0.0 f1- 50.0 ft. 12.0 in.
.375 CARBON STEEL
Company Name
W R050014 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#' FROM I 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.
Water Supply Well: 17.SCREENFROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring IaJRecovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PAC K ifa 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 ifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type rain size,etc.
0.0 ft. 1.5 ft- CONCRETE
4.Date Well(s)Completed: 09/21/20 Well ID# EX-49 1.5 ft. 44.0 ft. PWR
5a.Well Location: 44.0 ft' 220.0 rt' ROCK
ROXBORO STEAM PLANT 1t. ft.
Facility/Owner Name Facility ID#(if applicable)
a. ft.
1700 DUNNAWAY ROAD SEMORA 27343 ft. ft.
Physical Address,City,and Zip
ft. ft.
CASWELL 21.REMARKS
County Parcel Identification No.(PIN)
OPEN HOLE-50.0-220.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
1981080.60 N 994718.58 W 111117% 02/15/21
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!5No 15A NCAC 01C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a copy
lJ'lhis is a repair,fill out known well construction information and explain the nature of the oJ'this record has been provided to the well owner.
repair wider 921 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 into
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.)
1--or nwhiple wells list all depths ifdiJJerent(example-3(a 200'and 1Q100')10. Submit this GW-1 within 30 days of well completion per the following:
14.64 24a. For All Wells: Original form to Division of Water Resources (DWR),
/fwater level is abm•e casing,use"+Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"
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