GW1-2021-00766_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) 7i_ernal Use Only:
1.Well Contractor Information:
�"- \­,�; I \z
NICHOLAS HAYES 7���
. O� s 14.WATER ZONES
Well Contractor Name ,,� FROM TO DESCRIPTION
A - 4121ft. rt.
' J ft. rt.
NC Well Contractor Certification Number R� 15.OUTER CASING for multi-cased wells OR LINER ifa licable
GEOLOGIC EXPLORATION i. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0.0 ft. 61.0 ft. 12.0 in .375 CARBON STEEL
���: '" 1;;�i' _ ..
v�yy" 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W R0500142 \" FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREENFROM TO DIAMETER SLOT SIZE 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
❑lrrl ation ❑Wel ls> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ARecovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soilhrock e, rain size,etc.
0.0 ft• 15 ft. CONCRETE
4.Date Well(s)Completed: 09/22/20 Well ID# EX-50 1.5 rt. 43.0 ft. PWR
Sa.Well Location:
43.0 ft' 53.0 ft' WEATHERED ROCK
ROXBORO STEAM PLANT 53.0 ft- 220.0 ft. ROCK
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1700 DUNNAWAY ROAD SEMORA 27343 ft. ft.
Physical Address,City,and Zip ft. ft.
CA S W E LL 21.REMARKS
County Parcel Identification No.(PIN) OPEN HOLE 61.0-220.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i��/�
(if well field,one lat/long is sufficient) 22.Certification: ��C/" J �
1981050.45 N 994749.95 W ivl/ 02/15/21
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this Jorni,l hereby cert�that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
tf lins is a repair,fi//out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under f21 remarks section or on the back oJ'this farm.
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
constriction,only I GW-I 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.)
fbr multiple weh,list all depths ifd�erew(example-3 tet 200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
17.99 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (11`0 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IJ'water level is above casing,use"+"
Ill.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
Permit Program, 161 1 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018