GW1--07477_Well Construction - GW1_20231120

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WELL CONST
RUCTIOI�II+jE��RD
1•.Wcll Contractor Info OnIY ° '
GW_1 m�
rOlation Use
Michael For lute
Well Contractor Moseley , . . . `
ON
rector Name '. TER�NES ,'DEs`.... _
`7f35 FnaM
e' NC Well Con ft.
if a Reable
Contractor cat. :or
QR LINER lytATERIALcation Number CASING in'
DIA ae� TNIC1a'IE�
. Summit De IS.OUTER
Cam sigh Engineering Services IS.O n• DTUaING eothcrmd ' MATERIAL
p y Name
lc INNER C NCrOR nIAM R,a-
2•Well Construcfioa.Pcrmit tt;
'LisFoll dpp!lcable well construction - FROM ft. - '
rt. In.
permits(<;e•U!C County,Semtc,Variance,arc.) ft'. -
` 3;Wei!Use.(checkwell use):, o. TlitclavFss ,
WatlrSu 17°SCREEN piAME'rER SWTSIZE
Supply Well: FROM rt To In
DAgriculturdl 15
�1MunictpaUPublic 10 2 iru
Doanthermal,(Heatipg/Cooling Supply), 0Residential Water Supply(single) ii 15, EMPLACEMENT METIIO &AMOUNT
umi
D
❑Industrial/CotntrSereial. OResidentialwatersupply(shared) is..GROUT Ti„ MATERAL
Olin lion - nom rt. berdOnite '
°Wells>100,000 GPD 8 ft. 5 t.5 bag Portland cement/0.5 ba0�nf0nite
Non-Water Supply Well: tL cetnenUbentonite
-LOMonitoring, ' :- - - ,ft. ',0
ORecoyery 5 ft.
Injection Well: rt r^';': r. :"
OAquifer Recharge DGroundwater Remediehon 19 SAND/GRAVEL PACK Ira cable EMPLACEMENT METHOD `
_ MATERIAL
OAquifer Storage and RecoveryFROM TO rt, Sand
❑SeliriityBarrier ft. 8
OAquiferTest ❑StormwaterDrainage 15r4
ft.
DExperimental Technology , 'OSubsidence Control sia ate
OGeothermal Closed Loop) 20.DRII LING LOG afMeho amnoN color tiredness eoSVroek +� '
( ❑Tracer .FROM TO
OGeothermal(Heating/Cooling Retum)': OOther ex lain under#21 Remarks) ft ft
7/3/2023: rt.
4:Date Well(s).domPleted: W LE-PZ-32S Well IINIft. - -- ..
Sa:Well Location , ., ' ft.9Y . .
Duke Ener MaY o Pla_ri ._t . `t
Facility/Owner Name- • Facility 101/(if applicable) ft. - ,' ' J 1. LI
'1'0660 Boston Rd,-Roxboro, NC 27574 ft
. , Physical Address,City,and Zip - - -
„Person 21.REMARKS
Parcel Identification No.(PIN)
, well pad and cover installed
'County - ,
• ` 5b.Latitude and'longitude in degrees/minutes/seconds or decimal degrees:
(ifwell'field;one lot/long sufficient) 22.Certification:
36 539286 N. 78.898016 W ag 013
_ _ - Signature of Cenifi ell Contractor Date
6 Isere)the well(s)..OPermanent or. OTemporary By signing this form,Ihereby certifr that the well(s)was(were)constructed in accordance with '
.Oyes or ltNo
'ISA NCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Slandards.and'that a copy
7 Is this a repair to au existing vino.
of this record has been provided to the well owner, °
- - If this is a repair,fill out known conrrructionoinh;rmtion and explain the nature of the
repair under it21-remarks section or on the back.f farm.
23.Site diagram or additional well details:
Geothermal Wells havtn the same You'may use the back of this page to provide additional well construction info
8.For GeoprobelDET orClosed-dLeop
g add'See,Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 Tor is needed.indicate TOTAL NUMBER of wells,
24.SUBMfnTAL INSTRUCTIONS
drilled:______----------:;.
rilled: (ft.)
th'below land surface: 15 j 00'and'2@l00`) Submit this GW-I within 30 days of well completion per the following:
9.Total well dap p -dr eremt(exampl aO2
• Formultipleteellslistallde rhs+f ll 10.6 (fe) 24a.'For All Wells: Original form to Division of Water Resources {1)WR),
•
10.Static waterievel below top
•
dosing:, Information processing Unit,1617 MSC,Raleigh,NC 27699-1617
1T,warer level is above c rsing,use (1n) 24b.For Inie`bon Welly;Copy to DWR,PrControl `
¢hole diameter: :gram,1636 MSC,Rale"eigh,NC 27699-1636 Underground•
Injection (I[JC}
', n sor. auger':
24c.For Water Su 1.and O en-Loo itheoethcoeunrmatylwRheetr:insWtallds:u Copy to the
Well constructionnethod:
1 e,auger,rotary+ ble>duel Pub ate,) county environments cal department o
( Y`YELLS ONLY 24d.For Water Wells roducin over 100 000_GPD to DW
R,WATER SUPRL . Method of test Permit Program,1611 SC; eigh NC'27699-161 I Copy CCPCUA
]3e.yie-ld(0Pm) ' Amount:
isinfeehpq hPea
13b D North CarolinaDeparunestofEnvirentueatal,Quality_Di ion ofWatetResotuces
Form GW I �-20
Revised18
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