GW1-2021-00772_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES r ,+ 14:WATER ZONES
Well Contractor Name + 1uT FROM TO DESCRIPTION
ft. ft.
A - 4121 ''
NC Well Contractor Certification Number
wt�t�� IS.:OUTER CASING for multi-cased wells OR LINER if-a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name s-�` 'ar .i�11 0.0 ft- 19.5 ft- 1 12.0 in. 1 .375 CARBON STEEL
r ass 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W R0500142 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable shell construction permits(i.e.UIC,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.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring (ERecovery ft. ft.
Injection Well:
rt. rt.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑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#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gimin size,etc.
0.0 ft• 14.0 ft. PWR
4.Date Well(s)Completed: 1 0/09/20 Well ID# EX-37 14.0 fr• 280.0 fr. ROCK
5a.Well Location: ft. ft.
ROXBORO STEAM PLANT ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1700 DUNNAWAY ROAD SEMORA 27343 ft. ft.
Physical Address,City,and Zip ft. ft. _
CASWELL .21.REMARKS:
County Parcel Identification No.(PIN) OPEN HOLE 19.5-280.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
1983241.32 N 994252.09 W 02/15/21
6.Is(are)the well(s)• [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this f rm,I hereby certift that the well(s)seas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction iglbrnration and explain the nature oJ7he of this record has been provided to the well owner.
repair under 1121 remarks section or on the back gfthis jornr.
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-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 list all depths ifdiifferew(example-3@200'and 2@100') Submit this GW-1 within 30 days Of well completion per the following:
10.Static water level below top of casing 46.3 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Uwater level is 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 mstalled
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-I61 1
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