HomeMy WebLinkAboutGW1--07476_Well Construction - GW1_20231120 . . . .
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WELL CONSTRUCTION RECORD(GW-1) .. . For.Intemal Use
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1.Well Contractor Information: . ,
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- Michael Moseley , , 14.WATER ZONES • i'
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• FROM To DESCRIPTION • ,
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Well Contractor Name , - ft. •ft. V,:
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18.OTHER CASING for multi-cased wells OR LINER if a licable - ,-NC
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NC Well Contractor Certification Number • f'
Summit Design & Engineering Services FROM 7'0
' , R. DIAMETER , THICKNESS MATERIAL
Company Nall= . 16.INNER CASING"TVBING mil_._,,__,--------11-j1--•-e=-PL--'------------.-losed-loo , 'mai , '/.;,'3
, DIAMETER 711ICKIVESS 1._______2#18 ILRIA - 1.•••
2.Well Construction Permit 0:
. . .ft : ft• in. ,-, , a,
List all applicable well construction permits(le.U1C,County,State,Kirk:Fee,etc.) , • „ , . r...,,
. . . ,, ft. ft. . in.
3.Well Use(check well me): • -,..-L-.-------
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Water Supply Well: 17,SCREEN • .DIAMETER SLOT SIZE• THICKNESS MATERIAL ,
' °Agricultural • ',OMunicipal/Public FROM TO
38 - ft• 18 II. 2
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°Geothermal(Heating/coo ling Supply) °Residential Water Supply(single) ft. 38 . ft. -
in.
Olndustrial/Commercial OResidential Water Supply(shared) 18.GROUT
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°Irrigation.t. OWells>100,000 GPD ,. FROM I TO , nuaTittm. EMPLACEMENTMETHOD&AMOUNT ct.,
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d , •
Non-Water Supply Well: , 16.4 ft• 12.7 ft bentonite c..;
elMonitoring ORecovery 12.7 ft• 0 • ft- cement/bentonite 1 bag portland cement/0.5 bag bentonite
Injection Well:Well:
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0Aqiiifer Recharge °Groundwater Remediation' " • -
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19.SAND/GRAVEL PACKfif applicable) .' . . i F
°Aquifer Storage and Recovery °Salinity Barrier ' FROM TO . MATERIAL . EMPLACEMENT METHOD .,
°Aquifer Test ' " . OStormwater Drainage . 38 . ft.. 16.4_ ft sand . , ,. , 14'
'ClExperimental Technology C3Subsidenee Control • fC
'',3-•
'ClGeothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if access erV) , ..
FROM TO DESCRIPTION(color,hardness.selfrock type,grain one.etc.) ' -
°Geothermal(Heating/Cooling Return) °Other(explain under 021 Remarks) , . , ft. ft., _ ..._ • i
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4. 7/6/2023 Date Well(s)Completed: - • Well ID#LFPZ33S 1"..t. ft. - - ._ .
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. ft.
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5a.Well Location: -- , ,ft
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rt. 'NO V :",/, 9 Z(J23
Duke Energy Mayo Plant ', ft. ,.,..:
' Facility/Owner Name , Facility ID,/(if applicable) . ft. - _.
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10660 Boston Rd, Roxboro, NC 27574 . ., ft. rt.
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Physical,Addresa,City',and Zip ,-, , , ft. ft. - ,
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Person ,I , 21.REMARKS ?
County Parcel Identification No.(PIN) ' " well pad and covet'installed:.
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51i.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) , 22.Certification: - .
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'36.5_35316' ' 78.899491
N . • s 1r
W ' 71-1"4.. --•
. • ' 7•19-.Z3 l'
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6.Is(are)the well(s): °Permanent or ItTemporary Signature of...ertifier411ll Contractor Date .N,,,,,•
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13y signing this form.1 hereby coil&that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: °Yes or No 15A NCAC 02C.0100 or 1SA.NCAC 02C,0200 Well Construction Standards and that a copy
lf this is a repair,fill out known well construction Information anderplain the whirl,of the of this record has-been proinided to the well owner.
repair under ti 21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobeMPTer Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I pw7i 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:38 (ft.)
For multiple wells list all depths ft-different(example-3®200'and 20:4100) • Submit this GW-1 within 30 days of well completion per the following:
10.Static water level.ber.ow top of casing:1 7.2 „
. .LI, 24a. For All Wells: Original form to Division of Water Resources (DWR),
" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use"," ..
IL Borehole diameter:3.25 (in.) , 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
, Program 1636 MSC,Raleigh,NC 2769971636, ,
it Well construction method:auger . 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copyto the
(1,e.auger,rotmy,cable,direct push,de.) , 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: '" ,
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136,Disinfection type: ,Amount: . • , ., ' ,
Form OW-I . ,
-. North Carolina Department of Environmental Quality-Division of Water Resources ,Revised 6-6-2018
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