GW1-2021-00768_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES ' ���' 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A - 4121 �< l• rr'� rr. fr.
NC Well Contractor Certification Number ^^�``l 15.OUTER CASING for multi-cased welts OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft. 19.5 ft 12.0 in .375 CARBON STEEL
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop),
2.Well Construction Permit#: WR05001 42 V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable we/1 construction permits(i.e.U/C,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. fr. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. tt. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrl ation ❑Wel Is>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring (Recovery
Injection Well:
ft. ft.
[]Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑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(Heat ing/Cool i ng Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck tyM gmin size,etc.
0.0 It. 2.0 ft. BROWN SILT
4.Date Well(s)Completed: 10/07/20 Well ID# EX-52 2.0 rt. 8 0 it. PWR
Sa.Well Location:
8.0 ft• 517.0 `t' ROCK
ROXBORO STEAM PLANT `r' `.
Facility/Owner Name Facility ID9(ifappticable) ft.
1700 DUNNAWAY ROAD SEMORA 27343
Physical Address,City,and Zip ft. ft.
CASWELL 21.REMARKS
County Parcel Identification No.(PIN) OPEN HOLE- 19.5-517.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
1983362.51 N 994283.25 W 14WA % 02/15/21
6.Is(are)the well(s): (SPermanent or ❑Temporary Signature of Certified Well Contractor Date
Hy signing this f trmh,/hereby certify that the wells)was(here)consirueied in ac•c•ordance 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
1l this is a repair,fill out known well construction information and explain the nature of the q1 this record has been provided to the use//owner.
repair tinder N2l remarks section or on the back ofthis f n-in.
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-1 is needed. Indicate TOTAL NUMBER of wells (add'Sce Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 517.0 (ft.)
For multiple wells list al/depths iij'dVferent(example-3 n 00'and 2 rCi/00') Submit this GW-1 within 30 days of well completion per the following:
32.9 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
If water level is above casing,use.
11.Borehole diameter: 6.0/10.0/15.0 (in) 24b. For Infection 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 ofthe 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