GW1-2021-00790_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: r"•�`
NICHOLAS HAYES
.14.WATER ZONES
Well Contractor Name ,fi' '1 " ** FROM TO. DESCRIPTION
ft. ft.
A - 4121 ,., �a TO�
ppt` \�l ')1. '' ft. ft.
NC Well Contractor Certification Number <
C ; 15.OUTER,CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION r }'�l FROM TO. DIAMETER THICKNESS MATERIAL
w'i j S'd,
0.0 f1 29.0 ft 12.0 in .375
Company Name CARBON STEEL
W R050014;2' 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counly,State,Variance,eta) ft. fI. in.
3.Well Use(check well use):
ft. ft. in.
Water Supply Well: 17.SCREEN
FROM 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)
IS.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ORecovery R. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 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 421 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,pmin size,etc.
0.0 ft 3.0 ft RED CLAY
4.Date Well(s)Completed: 10/06/20 Well ID# EX-53 3.0 ft 20.0 ft PWR
5a.Well Location: 20.0 ft 501.0 ff ROCK
ROXBORO STEAM PLANT ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1700 DUNNAWAY ROAD SEMORA 27343 ft. ft.
Physical Address,City,and Zip ft. ft.
CAS W E L L 21.REMARKS'
County Parcel Identification No.(PIN) OPEN HOLE 29.0 501.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
1983398.01 N 994216.47 W � 02/15/21
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing This form,/hereby certifj,that the well(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo I5A NCAC 02C.0100 or 15A NCAC 02C.020t1 Well Construction Standards and that a cony
f this is a repair,fill out known well construction information and explain the nature q/the oJ'thi.s record has been provided to the well owner.
repair under.21 remarks section or on the back of 1his 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-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: 501.0 (ft.)
(or multiple wells list all depths ifili ferent(example-3@200'and 2@/00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 28.89 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"T
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 lnjection 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018