GW1-2022-05627_Well Construction - GW1_20220610

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATERZONEs
Well Contractor Name FROM TO DESCRIPTION
A - 2581 rr. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi cased wells OR LINER if a liceble
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I in.
Company Name
'16.INNER CASING.OR OR.. 'eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc) 0.0 ft. 260.0 fi- 2.0 In' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN•
FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 260.0 fr. 280.0 ft' 2.0 in: 010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft, 245.0 ft- PORTLAND,BENTONRE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
❑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 257.0 ft- 299.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control fr. fr.
❑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,soiltrock e, rain sin,etc.
0.0 ft• 8.0 ft- BROWN SILTY SAND
4.Date Well(s)Completed: 05/12/22 Well ID# PMW-01 D 8.0 tr. 26.0 ft• PWR
5a.Well Location: 26.0 ft. 299.0 ft' ROCK
ROXBORO STEAM PLANT ft. ft. ,
Facility/Owner Name Facility ID#(if applicable) ft. ft. ti a
1700 DUNNAWAY ROAD SEMORA 27343 ft. ft. JUN 1
Physical Address,City,and Zip ft. ft.
PERSON 21.REMARKS Pj"'.Uu:, l Ufg
County Parcel Identification No.(PIN)
BENTONIfE SEAL-245.0-257.0 FEET i cs
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: �
360 28' 53.12" N 790 04' 13.16" W n;,,, r---
06/02/22
6.Is(are)the well(s)' EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,l hereby certt&that the svell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Mo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards-and that a copy
lf'this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under'21 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-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.)
For multiple wells list a//depths iftli ferent(example-5 cer 200'and 2 a 100') Submit this GW-1 within 30 days!of well completion per the following:
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177.0 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
If water level is above casing,use"+"
11.Borehole diameter: 6.0 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR f
24c.For Water Supply and Open-Ltiop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 2 7699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
(t{
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018