GW1-2021-00769_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD.(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES , 14.WATER ZONES
Well Contractor Name `r^'y� FROM TO DESCRIPTION
A - 4121
NC Well Contractor Certification Number �,� `d
fr. ft.
.,
O� 15.OUTER CASING for multi-cased wells OR LINER(if a licable
GEOLOGIC EXPLORATION b" �OJ FROM I TO HI DIAMETER TCKNESS MATERIAL
Company Name
0.0 ft- 29.0 ft- 12.0 in. .375 CARBON STEEL
� „crj,•'-'_..��1
i' 16.INNER CASING OR TUBING eothermat closed-loo
2.WCII COOStrUCtlOn Permit#: WROSOO142:•;1r'' rr`` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Enuirly,SrafC,°Variance,etc.) ft. ft. in.
3.Well Use(check well use):
,y ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fr. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ORecovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL 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 I TO. DESCRIPTION color,hardness,soil/mck type,gnin size,etc.
0.0 ft- 23.0 ft- PWR
4.Date Well(s)Completed: 10/19/20 Well ID# EX-34 23.0 ft- 280.0 ft ROCK
Sa.Well Location:
fr. ft.
ROXBORO STEAM PLANT ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1700 DUNNAWAY ROAD SEMORA 27343 f. fL
Physical Address,City,and Zip
ft. fr.
CASWELL 21.REMARKS
County Parcel Identification No.(PIN) OPEN HOLE-29.0-280.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
1982981.06 N 994367.02 W All A f 02/15/21
6.Is(are)the well(s)• (EPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance tviih
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If Iliis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 921 remarks-section or on the back of 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
construction,only I 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: 280.0 (ft.)
For multiple wells/isi all depths ifdii ferew(example-3@200'and 1@100') Submit this GW-1 within 30 days of well completion per the following:
42.76 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,INC 27699-1617
!l�water er level it above casing,use"
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 G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018