GW1--07048_Well Construction - GW1_20231102

For Internal Use Only:
1.Well Contractor tnformntlon:
. -.--,4.III ' G. . - ht.W Arai ZON
WeflCorotrctor'Namnc mom To
7 /t r
NC Well Connector CertificationNumber fi' n
Ltw>rt �°"/. 1 J r�/ IL OUTER CASIrt...NO(few m wells)OR LINER JttAatKTER •Ht walkable/.
Company Name •- It, p ENSIIS MNfsN1AL�`
16.INNER C /�2.Well Construction Permit#: /i c .►7 , }d mom ,ro NG OR Ttt6RYG I
List all applicable tseil construction ftfA7 GttfAi p its(i,r.We Ctwatlt•,Slate,YaNutice,err.) ft. n, �,
3.Well Use(cheek well use): `fir ''''" e-r y e,t
ft. q, le
Water Supply Well: - 17.IiCRL'KNnom ..
°Agriculttual OMunicipal/Public utxitltrtr Oman yytgt INAsir w
❑Oeathermal(Heating/coolingsupply) °Residential Water SupplyIn,
'W>P y) '(single)
C1lrrdustriaUCtxninexciai �� �� ._..._...�
Clfeaidential Water Supply(altered)
ver " —)
Clhrigation OWells s 100,000 GPI) non To m
Non-Water Supply Well: '""�"e1A+ �+� ttotr ,lt,ur
+t. i3.
°Monitoring °Recovery
nlectiun We : rt. g �_._-__)
t�rtgaifer Recharge .rottrvdwatrr Kcrned1ation R. rt.
f
DAquifer Storage and Recovery I3Saliniry Batricr 19.MNlMRAVEL 'ACK ,
L7Agnifer Test ratio 'to
C1Stonnwater Drainage ft. ft.
°Experimental Technology °Subsidence Control ft
ft.
°Geothermal(Closed Loop) tJTtacer 20.D1t1LLIN0 LOG(attach addi111md sherd If
°Geothermal(Heatin oolin Returnswim To rl __...
$ ) taco(explain under#21 Ratnerits) imsG nertort&We,bantam,soWtvek tiffetMe the.psi.) i
0 ft. .cc
ft
6.Date Wells)Co pleted: Weil UV M— I3 2 S ry' 7 ,n' ,,, l it ' fi r t-a,S4Q .(t� C
Su,Well Location: -�•
ft. n.
1r C a,rt~1>�ezt►� s� P rt, ft. • _
vily
Facility/Owner Name Facility toe(ifappticabk) ft. rt. -W
z f ?tt v i31lad;ctc„x ,v✓�'jl� ft t NOV J 2 20[3 ' .:.,
Physiall Addicuc.City,and Zip ¢ ft. ft _ _._
ON..sl0 w #3 leiloy78,1 21.REMARKS
County Parcel tdentittention No.(PIN) :J 7 ,( Q,✓ Ls).k/(
5b.Latitude and longitude in degrees)ndnueeaheconds or decimal degrees: See.o, edf xc t".0.1.1'c.!are, ,v iret t; iv j e i j
(it well livid,one iat/long is sufficient)
22.CertNiceden:
' -71i!yeat► IN " .77, 346dUtro w
iQ--)Er.,23
6.Ware)the well(s): tl ermanent or °Temporary Signature 1'Ccnifrod Well Contactor Date
,I B si grog thisiteiu.I keI eSy act*j�J'that the ire/lft)Was(were)co ter retell In accv,rlanct mhh
7,is this a repair to an existing well: Dyes or (!No List NCAC 02C.OIOt?or 134 NOW 112C.rz20O Well C'on:Arnrtton Standard!and That p ropy
Ifth/s Ls a rwpalr,.Jlll out known 44,11 construction InfOrsiation and ecplain the nature of the of this record has been provided so the suP owner,
rpuir under#2I Penh,ph section or an the back ofihta forgo.
23.Site diagram or additional well detaW:
You may uac the back of this page to provide additional well construction info
i;,For C.eoprebeJD1'T or Closed-Loop Geothermal Welk having the same
conatetaction telly I CiW-1 is needed. Indicate TOTAL NUMBER dwells (add'See Over''in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUDMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiply stvlis lest n/i ifdi erenn (D') Submit this GW-1 within 3p d s of well completion
"tgitt+r l7 (rtamplr-3(a�200'na`aiplilrYjnY per the following:
10.;Static water level below top of easing: +/Q 24a. For AN Wells: Original form to Division of Water Resources (DWR),
1/water level is above casing,rue"+' ("') Information Processing Unit,1617'MSC.Raleigh,NC 27699-16'17
II,Borehole diameter: P (in.) 24b.,For lnleciipn Wellet Copy to DWR,Underground Injection Control(IUC)
? Program, `636 MSC,Raleigh,NC 27699-1636
l
12.Well construction method: , C1 fa.'51 WI . - 24c.for WeaerSet�lqtb�j and Open-Loop 1 Return Wells:Copy to the
tie.wwgrr,rotary,cable,direct posh,cm) county 1yeaitb department th
GnsltoirillEYrta Cps county wlrett installed
FOR WATER SUPPLY WELLS ONLY: 24d.Far Water W_producing over jilii,000 GPD: Copy to DWR,CC'PCI lA
13a.Yield in Permit'Progntm, MtSC,Raleigh,NC 27699-1611
(gp ) Method of teat:
tab.Disinfection type: Amount: ,W, _ __
Form GW-i

44101 Multi-Phase Extraction Well Revision#:_0
TERRATHERM Release date:_5/12/23_
fe.r:r M�f'r,r l l'.Inv
Construction Detail
Approved by:_--^^SL_
Well ID M-13 Date - .mil Cq - a 3
Oversight ' L„. Job# R23-104
Driller 1 1.-s
Design Constructed Notes
(fill out if
Well Diameter 4" different)
Borehole Diameter 8" ------Stick Up Height 36"
Ground Surface 0.0'
HT Grout---------— 1111---�
Angle from Horizontal 90"
Top of#00 Sand 1'
Casing Material
Carbon Steel . Top of Screen 3'
Other:
Riser Length 6 ft
Screen Length 17 ft Bags of#00 Sand 12
NM. Bags of Cement 1.25
IN •
Bags of Silica 0.5
Screen Material
Stainless Steel Borehole Diameter 8"
— —.
Fiberglass
PVC
Other:
Slot Size 10 Bottom of Sand 20'
_ _ Bottom of Screen 20'
• •
Installation Method _-—
Sonic HT Grout--
Hollow Stem Auger Sump Length 2'
Mud Rotary
Other: Bottom of Sump 22'
Bottom of Borehole 22'
Post-Installation QC(to be performed 24hrs after installation) PID Log:Make/Model:
1)Confirm well is free of grout Design Constructed Time: I 1 3 Reading: Q Q PPM
Depth to bottom of well[ft bTOC]: _25._ Time: Reading: PPM
if greater than or equal to lit less than designed alert the office Time: Reading: PPM
2)Confirm grout plug reaches ground surface Time: Reading: PPM
repeat daily until depth to grout is Oft bgs Time: Reading: PPM
Date Depth to Grout[ft bgs] Notes: