GW1--07051_Well Construction - GW1_20231102

WELL CONSTRIXTI N RECORD(G'W.711 For Internal Use Only: - ..
1.Well Contractor leformatlon:
.,..__ Ye_il Y (:,'IZIAr
Well Contractor Name
is yvA hR di
IrRdP} To7AN8 niggn nov -
? 70 ft. g, 'f
NC Well Contractor Certification Number ft R
/ ,l p 15.o.ratomwn mama(tor at T LINER
atANIUtTitit in. MA'trtl.
C'onmsny Name ft. R.
2.Well Construedon Permit if �`f j' 16.INN `CASING OR 1 G a�i eleseB-Ioep)
larr all applicable well conrn7rctinn . FROM, 17ttC%N1tp¢ MAMMAL
Is�:r.WC�ittntlwpbStait.Yarfartce,err.) It R, in.
3.Well Use(check well use): Arow(`rr J ek:r e-
-
R. R. M.
Water Supply Well: It SCREEN
DAgricuittuai C7Mtwicipal/I'ublic PROM-it
. aiAnt attTMut -ineitlttAL.
°Geothe mal R. in
{H�tint;/Couling Supply) pReeidwrtiel Water Supply(single)
C1ltiduvttiaUComnutrcial rt'. _ ft h‘
ClResidential Water Supply(shared)
CIh'rigatiun 48.C: 1 ,:. . .
i Wells> 100,000 OPO tfaom-
Non-WaterSupllly'Well; ht MAT}kRtAt; JC+►t>! ►CRMEM1�t�lt�pc,yalxlvr
R. ft.
DMonitorin(y ° ov
Injection Well: Y,, Itft. )
°Aquifer Recharge di nawater Retnoxiietirnt H. �T �'
DAquifer Statage and Recovery C1Salinity Sorrier IL NAAGItiVICt PACK Or, bit) 'PROM
To trldrtw *wet*f7At;uifer Test OStormwater Drainage R. k,
fl xperiniental Technology °Subsidence Control Ii. ft.
C](ieothermal(Closed Loop) DTr seer 2Q f tftA11YG �(, "'fluke! � )
D(ieoithetnial(Itestin /(ogling Recent) (explain under#21 Remarks) k e
L /i sdYrrK#trpc,,nrYta she ac.)___
4.Date Well(s)C R,„Lei"- )+I CJ ral S t,t •.� •.
Completed: Well i M / 0 rL ft. ,+yi�.— Errerlka Ay) Z-S�Ar
5a.Well Location: 14.tL)7 ft R. ! --
/), " Coed-Pour Ce ,err Stra'f Zmit SS,t`j e +Y&O 4 rib �;/ R it
pacility/Ow•nerName Pecttity IDS(ifmppiiaable) n. st NOV J 2 71121
x/ 7 Z,Ife n.e'!5 $41. (tilto,vi/>'lie, 2S3"yt' ftft.
Physical Address.City,and Zip b R. �_,, -- .._.
ON.s/o Lc) 1/3?11l3a i78J 8 21.REMARKS __`
County Parcel Identification No.(PIN) C k i''i4,/ C--mail (4)Z If
Sb,Latitude and longitude in degrees/minutes/seconds Indtuptedaecouds or decimal degrees: See' 11 e+o h.uC,♦'t5rr_'E"r t.�a r e f",v..fI,raq f`iv ivy a eta 1s.
(if wen field.one tat/king is sufficient) 22 Certification:
34.71i,11ao N -77 3d/10p W
6,ta(aru)the weli(s): 41 ermarttnt or CTTer orrry Signature of Certified Well Contractor Date
By signing this firm,I hereby wan,that the ael/rt)was(were)contra acted in artwntatires with
7.Is this a repair to an exising well: °Yes or V 1:T.A NCAC 02C^.0100 or I-SA NC%C 02C.0200 Well Construction Standards and that a cant
117his is a nywir,,llll art known well conxtruetion infortnettran and explain the nature of the ofthts record*ae then pratided to the wrli owner,
?VOW under t121 remarks section or on the back o(thta fores,
23.Site diagram or additional wail details:
8,For Ceoprobt/1)PT or[lased-Loop Geotherm ei WeUe having the same You may use the beck of this page to provideadditional wellconshvctitrn info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
Q 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: le Ct
(R')multiple nails lice all r/rNthc ifSubsoil this GW-1 within 30 days of well completion r the following:
F'ar multidifferent fi..rttrrrpk-3Qe�fJ(t'and XItlti) Y P Pe
10.Stade water level below top of casing; /Q (R.) fir• For AN Wells: Original form to Division of Water Resource.: (DWR),
1>a err tevtl ir above eating.me" ("� Information Processing Unit,1617 MSC,Raleigh,NC'27690-1617
11.Borehole diameter: CJ (fe) 24b. for Iglectiun Wei:Copy to DWR,Underground injection Control(IOC)
/� Program,i636 MSC,Raleigh,NC 2 7699-1 63 6
'
12.Well construction method: ' tc�.., tWi'. 24c.For Water Su(IC auger,rotary,cable,direct push,etc:) Supply and Open-Loop the county ReturnreWells:Copy to the
county envircm►nental Tenth department of the county where installed
FOR WATER 5UPP1,Y WFI.LS ONLY: 24d.For Water Walls producittf over 10i000 GPD:Copy to DWR,CCPCt1A
13a.Yield(spin) Method of teat: Permit'Program, 1611 MSC.,Ratcrg t,NG 27699•t61 I
13b.Disinfection type: Amount:,,,,,,_ . _____ -..-..w..
Vann C,W-i wt,.$.- _.,:_•........

TERRATHERM Multi-Phase Extraction Well Revision a: 0
. ,.. Construction Detail Release date_5/12/23_
Approved by:_SL
Well ID M-10 Date {S "'-g" 1 i
Oversight . Job# R23-104
Driller _ . '
Design Constructed Notes
(fill out if
Well Diameter different)
Borehole Diameter ------Stick Up Height 36
Ground Surface 0.0'
HT Grout-
Angle from Horizontal 90°
_ Top of#00 Sand 1'
Casing Material
Carbon Steel Top of Screen 3'
Other:
Riser Length 6 ft 1 _ _
Screen Length 63 ft :_:_IN
of#00 Sand 40.75
Bags of Cement 1.25
Bags of Silica 0.5
Screen Material
Stainless Steel _-_ Borehole Diameter 8"
Fiberglass
PVC . —
Other: '
Slot Size 10 Bottom of Sand 66'
Bottom of Screen 66'
Installation Method
onic HT Grout -
Hollow Stem Auger Sump Length 2'
Mud Rotary
Other: Bottom of Sump 5�
Bottom of Boreho 68'
Post-Installation QC(to be performed 24hrs after installation) PID Log:Make/Model:
1)Confirm well is free of grout Design Constructed Time: ID Reading: , 4 PPM
Depth to bottom of well[ft bTOCJ: 7t' Time: / / Reading: ( V PPM
if greater than or equal to Ift less than designed alert the office Time: 7r 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: