GW1--07481_Well Construction - GW1_20231120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: • ' .,:
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1.Well Contractai,Information: r'1
Michael Moseley 14 WATER ZONES
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FROM TO DESCRIPTION -
Well Contractor Name ti R. • •-,
. 4356
n. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap Ileable) ,4
Summit Design & Engineering Services
FROM TO DIAMETER . : THICKNESS MATERIAL
R. ft. in 4 _
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit 11: FROM TO DIAMETER • THICKNESS MATERIAL
Lint all applicable well construction permits(i.e.UIC County.State,Variance,etc.) ft. ft. tn. ' '
i w,
3.Well Use(check-wenuse): R. ft. hi.
Water Supply Well: 17.SCREEN . .:;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL I;,
❑Agricultural ❑Municipal/Public 32.8 its 17.8 rt. 2 In. i
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R• 32 8 ft• to :4:,.
❑lndustrial/Commercial ❑Residential Water.Supply(shared) to GROUT
' ❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT '
• Nan-Water Supply Well: 15.4 f' 12.5 R• bentonite vti
OMonitoring •ORecovery _ 2,5 R (1 fL cemenUbontonite 1.5 bag porl'and cement/D.5 bag bentonile r
Injection Well: is tL
t ❑Aquifer Recharge ❑Groundwater Rentcdiation It
l9.SAND/GRAVEL PACK{ifaPPllable)
j ❑Aquifer Storage and Recovery ❑$aliniry Barrier FROM TO MATERIAL IwMPIACFMEhT MLr1IlOD N,
,i ❑Aquifer Test ❑StormwaterDrainage 32.8 it 15.4 ft. sand I, .l
❑Experimental Technology ❑Subsidence Control ft. ft. I. • - i'.
1 ❑Geothermal(Closed Loop) ❑Tracer` 20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under ft2l Remarks) FROM TO DESCRIPTION(totem hard nest relFroe4 type entn ate,eta) t'
ft. ft. „i
4.Date Well(s)Completed: 7/3/2023 Well IDt9 LF-PZ-34S ft. ft. [,
fL it Well Location: - '
Duke Energy Mayo Plant ft it f
Facility/Owner Name Facility 1011(if applicable) ft. ft. NOV LI�L3
10660 Boston Rd, Roxboro, NC 27574 ft. IL N
Physical Address,City,and Zip It. ft. 4
Pe2L REMARKS a`
e:
County
• parcel Identification No.(P1N) Well pad and GOVef Installed
i•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if well field,one let/on22.Certification: F-'Jr!
� g is sufficient)36.535512 N 78.898814 W „,,,464 9P/s1
' '
6.Is(are)the well(s):'`l7Permaoent or Temporary Signature of esnfi e0 Contractor Dare is'
By signing this jorni,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or elNo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature niche of this record has been provided to the well owner.
repair under 421 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may usc,the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'Sec Over'in Remarks Box).You may also attach additional pages if nececsary:
.construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS '
8 (ft)9.Total well depth,below land surface: 32. Submit this GW-1 within 30 days of well completion per the following:
For multiple we&list all depths if different(example-3Q200'and 2(0100)
20.6 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 eating,use"'" 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 3'2 5 (10) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:auger______------------ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
etc.) county environmental health department of the county where installed
(ie,auger,rotary,cable,direct push ,
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
Method of test:
13a.Yield(gpm) . .
Amount: -
136 Disinfection type ---------r .
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Fenn GW-I
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