GW1-2021-00789_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES `" -
,���"�1 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name %''��" � 1 t ft. ft.
A - 4121 ,.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
V 0.0 it 44.0 ft 12.0 i"
Company Name .375 CARBON STEEL
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16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W R0500142 FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in,
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. fr. in.
❑Industrial/Commercial OResidential Water Supply(shared) I8.GROUT
Olrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring INRecovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater 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, min size,etc.
0.0 ft 5.0 ft SOIL-FILL
4.Date Well(s)Completed: 1 0/20/20 well ID# EX-32 5.0 ft 25.0 ft PWR
5a.Well Location: 25.0 ft• 40.0 ft' WEATHERED ROCK
ROXBORO STEAM PLANT 40.0 ft 280.0 it ROCK
Facility/Owner Name Facility ID9(ifapplicable) ft. ft.
1700 DUNNAWAY ROAD SEMORA 27343 ft. ft.
Physical Address,City,and Zip ft. ft.
CASWELL 21.REMARKS
County Parcel Identification No.(PIN) OPEN HOLE-44.0-280.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
1982850.86 N 994426.74 W //W/ � 02/15/21
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form I hereby certify that the we/l(.$)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I9N0 l5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Smndards and that a copy
!/•this is a repair,fill out known well construction information and explain the nature oflhe ofthis record has beennrovided to the well owner.
repair under:2/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-I 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.)
!or nu ltiple wells list all depths ifdierent(example-3 a 00'and 1@/00') Submit this GW-1 within 30 days of well completion per the following:
36.85 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/jwater 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 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 OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018