GW1-2021-00779_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES ��, �,y�l 14.WATERZONES
Well Contractor Name a t FROM ft• TO ft DESCRIPTION
A - 4121 tip' ��
�j 3 ft. ft.
NC Well Contractor Certification Number p A(, n ;�'•`
\V\r' (_'1 "t' 15.OUTER CASING for multi-cased wells OR LINER ifa livable
GEOLOGIC EXPLORATION f FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft. 24.0 It- 12.0 in .375 CARBON STEEL
rr+ri:,�`";.
Company Name ``' yam, ,
W R050014 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable,veil construction permits(i.e.VIC,County,Stale,Variance,etc.) ft. ft.
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
❑lrrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
❑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,soillmek type,grain size,etc.
0.0 tr. 15.0 ft. PWR
4.Date Well(s)Completed: 09/28/20 Well ID# EX-22 15.0 ir• 220.0 fr. ROCK
5a.Well Location: ft. ft.
ROXBORO STEAM PLANT
Facility/Owner Name Facility lD#(ifapplicable)
1700 DUNNAWAY ROAD SEMORA 27343
Physical Address,City,and Zip ft. ft.
CASWELL 21.REMARKS
County Parcel Identification No.(PIN) OPEN HOLE-24.0-220.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 22.Certification:
1981930.43 N 994410.37 W 11zA� 02/15/21
6.Is(are)the well(s)• I!flPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I9No 15A NCAC 02C.0100 or MA 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 of this record has been provided to the,veil oumer.
repair under All remarks.section or on the back o(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 ifdiJfereni(example-3 tJ 00'and 2 a@100') Submit this GW-1 within 30 days of well completion per the following:
3.88 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
lflvaler level is above casing,use"+"
6.0/10.0/15.0 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
IL Borehole diameter: (in.) 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 61 1
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018