GW1-2021-00778_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 9..`t� �:.+•,y FROM TO DESCRIPTION
ft. ft.
A - 4121
NC Well Contractor Certification Number ^t` 15.OUTER CASING for roulfi-cased wells OR L►NER if a licable
GEOLOGIC EXPLORATION ��\N� ADM TO DIAMETER THICKNESS MATERIAL
' 10.0 ft. 22.5 ft- 12.0 in .375 CARBON STEEL
Company Name `�� •••'1
W R0500142 c. {
-rt7,,. t^ ,,s 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit# \ya0°R° r'��j V�i FROM TO DIAMETER I THICKNESS MATERIAL
List al/applicable well construction permits(i.e.VIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): fr. fr. 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 atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring INRecovery ft. fr.
Injection Well:
ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK-ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater 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,grain size,etc.
0.0 ft. 15.0 ft. PWR
4.Date Well(s)Completed: 09/28/20 Well ID# EX-21 15.0 fc. 220.0 fc. ROCK
5a.Well Location: ft. ft.
ROXBORO STEAM PLANT fr. fr.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1700 DUNNAWAY ROAD SEMORA 27343 ft. ft.
Physical Address,City,and Zip
rt. I ft.
CAS W E LL 21.REMARKS
County Parcel Identification No.(PIN) OPEN HOLE-22.5 220.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification: ,��iY!
1981873.51 N 994400.12 W 02/15/21
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this Jorm,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Ves or MNo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the oJ'Ihis record has been provided to the well owner.
repair under 421 remarks section or on the back of this 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 ifdifferent(example-3@200'and 2@/00')10. Submit this GW-1 within 30 days of well completion per the following:
0.25 24a. For All Wells: Original form to Division of Water Resources (DWR),
fwater level is above casing,use"+" m Stalk water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lJ
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 GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018