GW1--03629_Well Construction - GW1_20230526

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
-1.Well Contractor Information:
BRIAN THOMAS ,4.WATER ZONES
Well Contractor Name
"- FROM .TO DESCRIPTION "
ft. ft.
A - 2581
rr. ft.
NC Well Contractor Certification Number :15.OUTER CASING(for multi-cased ivells)OR LINER if i i,licabTNEI
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft.
Company Name
16:INNER CASING OR TUBING( eothermal closed-loo h
2.Well Construction Permit#: FROM, TO I DIADIETER TtucKNESs I MATERIAL
List ol!opplicable it-of/consiriklioo permits(i.e.111C Counly,State,Variance.etc.) 0.0 ft. 200.0 ft. 10 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply'Well: 17.SCREEN
FROM 'TO DIAMETER SLOTSIZE THICKNESS' MATERIAL
❑Agricultural ❑Municipal/Public 200.0 fr, 220.0 ft 2.0 In- .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. rr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT NIETHOD S ANIOUNT
Non-Water Supply Well: 0.0 ft• 162.0 ft- AQUA GUARD SLURRY .
®Monitoring. ❑Recovery ft. ft.
Injection Well: fr. tr.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK(ifa.
P tlicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I ENIPLACEMEN'T METFIOU
❑Aquifer Test ❑Stormcvafer Drainage 197.0 f' 220.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology OSubsidence Control ft: ft.
❑Geothermal(Closed Loop) - ❑Tracer 20..DRILLING COG'(attach additional sheets if necessary) _
FROM TO DESCRIPTION(color,hardness,soil/rock t e; rain size,etc.
❑Geothermal(HeatingLCooling Return) ,❑Other(explain under#21 Remarks)
0.0 ft. 17.0 fr• OLIVE BROWN SILTY SAND
4.Date Well(s)Completed: 04/25/23 Well ID# PMW-04.BR 17.0 ft. 220.0 tr• BEDROCK
in.Well Location: J ft.
ROXBORO STEAM PLANT
Facility/Owner Name Facility lDd(ifapplicable) ft.
1700 DUNNAWAY ROAD SEMORA 27343 ft. ft. 4 7 2023Physical Address,City.and Zip ft. ft Irh`vt"Pi; :evil :�C:-;':r.•"�: � I i ,;
PERSON 21;REMARKS
County - Parcel Identification No.(PIN) BENTONITE SEAL_ 162.0-197.0 FEET
Sb.Latitude and longitude in degrees/mi6utes/seconds or decimal degrees:
(ifwell field,one lit/long is sufficient) -
22.Certification:
994644.1 N, 1982078 W 05/15/23
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
Lay signing this.1brm,1 hereby certify that the u•e//(v)tros(were)constructed in occ•orclanc•e with
7.Is this a repair to an existing well: ❑Yes or MNo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constrnetion:Standards and that a cope
/fthis is a repair,fill out known ire/l construction information oud erplain the nature of the of"this record has been provider/to the trell owner.
repair under v 21 rent arks 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 into
construction,only I 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 ntnhip/e wells Its'an depths ifdiJJereut(example-3 cr1200'aed 25/00') Submit this GW-I within 30 days of well completion per the following:
(ft.
10.Static water level below top of casing:
42,5 ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwmer lerellt above caving,use"+ Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Bm ehole diameter: 10.0/6.0 (ill) 24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/AIR
24c.For Witter Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger.ratan-,cable,direct push,etc.) county environmental health department of the county where installed
FOR 11'ATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,060 GI'D: Copy to DWR,CCPCUA
13a.Yield(gpnh) Nletliod of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Amount:
Fat in GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2013