GW1--07765_Well Construction - GW1_20231201

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information: •
. JOHNNY BURR- 14.WATER ZONES -1 -1
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 3098
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
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Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,Stale,Variance,etc.) 0.0 ft• 10.0 ft. 2.0 ' in. SCH 40 PVC
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0 ft. 40.0 ft' 2.0 in' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL , EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 6.0 ft• PORTLAND BENTONITE SLURRY
lMonitoring ❑Recovery ft. ft. ,
Injection Well: '
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑StormwaterDrainage 8.0 ft' 40.0 ft. 20-40i, FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
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❑Geothermal(Closed Loop) • ❑Tracer 20:DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft' 9.0 ft' . RED/BROWN SILTY SAND
4.Date Well(s)Completed: 1 1/14/23 Well ID# LF-PZ-39S 9.0 ft. 12.0 ft. ROCK
5a.Well Location: 12.0 ft' 13.0 ft' PWR/LIGHT BROWN SANDY SILT
MAYO STEAM PLANT 13.0 ft• 40.0 ft• ROCK 1�� "--j
ft. ft. 4.a,...Q: { •..,
Facility/Owner Name FacilityIDff(ifapplicable)
10660 BOSTON ROAD ROXBORO 27574 ft. ft. Jr r
Physical Address,City,and Zip
ft. ft. 2023
PERSON 21.REMARKS
BENTONIfE SEAL 6.0 8.0 FEET
..,D v'r'sC,y ;;;':;=.,1-'1'1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36° 53' 87.40" N 780 89' 78.87" W 11/20/23
6.Is(are)the well(s): lPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,!hereby certify that the well(s)was(were.)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo ISA NCAC 02C.0/00 or I5A 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 of the of this 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:
S.For Ceoprobe/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 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: 40'0 (ft.)
For multiple welds list all depths if different(example-3@200'and 2 tt l00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 1 8.5 Ift) 24a. For All Wells: Original form;to Division of Water Resources (DWR),
If waver level is above casing,use"+^ Information Processing Unit,1617 MSC;Raleigh,NC 27699-1 6 1 7
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 HAMMER
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) 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: 1
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13b.Disinfection type: Amount:
Forms GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018
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