GW1-2021-00773_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 41 14.WATER ZONES
Well Contractor Name ,t-*'i rti�;.° FROM TO DESCRIPTION
A - 4121
Y ft. ft.
NC Well Contractor Certification Number +�N 15.OUTER CASING for multi-cased wells OR LINER if a- licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
FROM
0.0 ft. 124.0 ft- 1 12.0 in .375 CARBON STEEL
Company Name `j� `' ^,';a
W R050014 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS, MATERIAL
List allapplicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): R. fr. 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
❑lrrl atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ORecovery ft. fr.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT.METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑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,soillrock tyM grain size,etc.
0.0 fr. 8.0 fr. PWR
4.Date Well(s)Completed: 10/08/20 well ID# EX-38 8.0 ft. 280.0 ft' ROCK
Sa.Well Location: rt. ft.
ROXBORO STEAM PLANT
Facility/Owner Name Facility ID#(ifapplicable)
1700 DUNNAWAY ROAD SEMORA 27343
Physical Address,City,and Zip ft. ft.
CASWELL 21.REMARKS
County Parcel Identification No.(PIN) OPEN HOLE-24.0-280.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
1983292.12 N 994269.78 W 02/15/21
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this firm,I hereby c•eritfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I9No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
//'this it a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under 4'21 remarks.section or on the back ofthis 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-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 ifdierew(example-3 a 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
44.2 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 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 Welts: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