GW1-2021-00767_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYE$ ej3 ;�����~ 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
..A .✓ tlorL ft. ft.
A - 4121 " 1•
NC Well Contractor Certification Number 15.OUTER CASING for ma1H-cased wells OIL if a Iicable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft- 24.0 fL 12.0 i" .375 CARBON STEEL
Company Name y, t'd'
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:
WR0500142 \b� FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable we//construction permits(t.e"U1C.County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. 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 ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring (Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa Iicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control fr. ft.
❑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,soil/rock type, iain size,etc.
0.0 ft- 12.0 r' PWR
4.Date Well(s)Completed: 10/07/20 Well ID# EX-51 12.0 ft- 338.0 ft- ROCK
ft. ft.
5a.Well Location:
ROXBORO STEAM PLANT fr. fr.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1700 DUNNAWAY ROAD SEMORA 27343 rt. It-
Physical Address,City,and Zip ft. ft.
CASWELL 21.REMARKS.
County Parcel Identification No.(PIN) OPEN HOLE 24.0-338.0 FEET
5b.Latitude and longitude in degrees/minti'tes/seconds or decimal degrees:
(if swell field,one lattlong is sufficient) 22.Certification:
1983330.73 N 994297.88 W 02/15/21
6.Blare)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing This form,1 hereby certiJj,that the mell(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!]No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
//'this is a repair,fill out known well construction information and explain the nature of'lhe of'this record has been provided to the well owner.
repair under-.'21 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 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: 338.0 (fL)
For multiple wells list all depths if'difjerent(example-3 200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:. 35.67 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
IJlvater level is above caring,use"
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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018