GW1-2021-00776_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 14.WATERZONES
Well Contractor Name „� ..y;t a V FROM ft TO ft DESCRIPTION
A - 4121
ft. ft.
NC Well Contractor Certification Number Rp
GEOLOGIC EXPLORATION \I\ - ) FROM ER CASING formulIAcasedwells OR LINER if a` licable
r FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0.0 fl 34.0 ft• 12.0 i" .375 CARBON STEEL
W R0500 i 4'2''s 16.INNER CASING OR TUBING eothermal closed-loopi
2.Well Construction Permit#: t FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE 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
❑Irrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring EURecovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft.
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL 1,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 To DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 ft. 25.0 1" PWR
4.Date Well(s)Completed: 10/28/20 Well ID# EX-19 25.0 ft- 220.0 1" ROCK
5a.Well Location:
rt. ft.
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
rt. ft.
CASWELL 21.REMARKS ,
County Parcel Identification No.(PIN) OPEN HOLE 34.0-220.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:1981663.99 N 994534.17 W /6��i/-A* 02/15/21
6.Is(are)the well(s): CEPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cerlify that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I9No 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,fill out known we//construction information and explain the nature of the of this record has been provided to the well owner.
repair under#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 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: 220.0 (ft.)
For multiple wells list all depths ifdi�ereni(example-3 a 200'and 1@I00') Submit this GW-1 within 30 flays Of well completion per the following:
83.78 24a. For All Wells: Original form to Division of Water Resources (DWR),
Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f lwater level is above caring,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 27699-1 6 1 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018