GW1-2021-00777_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES
�-n o-I - FROM TO DESCRIPTION
Well Contractor Name a I) +.� .,9 ` ft. ft.
A - 4121
ft.
NC Well Contractor Certification Number 1.5 OUTER CASING for multi-cased wells OR LINER if a ticable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
0.0 it 32.0 ft 12.0 i" .375 CARBON STEEL
Company Name �n i1�s y t ,'t' 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W R05001 42 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernius(i.e.UIC,County,State,Variance,etc) ft. fr. 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) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ORecovery ft. ft.
Injection Well:
ft. tr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑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/mck type,grain sin,etc.
0.0 fr. 28.0 ft. PWR
4.Date Well(s)Completed: 10/27/20 Well ID# EX-20 28.0 ft 220.0 ft' ROCK
fr. fr.
5a.Well Location:
ROXBORO STEAM PLANT
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1700 DUNNAWAY ROAD SEMORA 27343 fr. ft.
Physical Address,City,and Zip fr. ft.
CASWELL 21.REMARKS
County Parcel Identification No.(PIN) OPEN HOLE 32.0-220.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �/f
(if well field,one lat/long is sufficient) 22.Certification: /A�C� �,���I� _ _
1981673.78 N 994475.81 W /N/!JJl/ ��* 02/15/21
6.Is(are)the well(s): MPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing This form,I hereby certify that the ivell(s)was(were)consiructed 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 is a repair,fill out known well construction information and explain the nature of the oI lhi.r record has been provided to the well owner.
repair under 921 remarks section or on the back o/Yhis 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 Ovet'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.)
!'or muhiple wells list a/1 depths ifdifferent(example-3@a 200'and 2 r@i/00') Submit this GW-1 within 30 days of well completion per the following:
2.36 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
/floater level is above casing,use"+"
11.Borehole diameter: 6.0/10.0/15.0 (in) 24b. For Infection 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
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