GW1--07080_Well Construction - GW1_20231103

WELL CONSTRUCTION,RECORD(GW-1) For Internal Use Only:; •
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I.Well Contractor Information:' i
W U, t r�-/y% Ai;MLber,1 if l4.WATER ZONES'`
Well Contractor.Name j FROM TO DESCRIPTION ,
3$ 7t✓ A tr. f
ft. . rt. I
NC Well Contractor Certifiention Number l ';
p •15.OUTER CASING(for multi-cased wells)OR LINER(If ap Ilcahle)
i/I.s--VC 6-61 e. �• r /1/,✓9j FROM ' • TO• '( DIAMETER : THICKNESS MATERIAL
Company Name;, fr. ft. i in,
.16.INNER CASINGOR TUBING(geothermal closed-loop). 2.Well Construction Permit#: •
N,A CLat,L f•S-°)Le. FROM TO. - . DIAMETER. THICKNESS MATERIAL List all applicable well construction pe lnits(i.e.UIC.-CotiutV.State.Variance,etc.) ' ft. ft. in. ,
3.Well Use(check well use): Jr:V"%ha iff,1-011 id el-+ y'e
ft ft, In.
Water Supply Well: 17.SCREEN, i . .
❑AaiCltltltml . . FROM TO DIAMETER SLOT.SIZE' THICKNESS . MATERIAL
❑Municipal/Public • ft. ft, • in.
❑Geothermal(Heating/Cooling Supply) . ❑Residential:Water Supply(single)
ft. ft. In.
❑lndustriaVCommercial .❑Residential Water Supply(shared) •• ❑irrigation 1S•GROUT .
❑Wells.>100,000 GPD • FROM ' 'PO MATERIAL• EMPLACEMENT METHOD S AMOUNT
Non-Water Supply Well: ft. - ft. ' '
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❑Monitoring ❑Recovery. . . ft. ft. •
Injection Well: .
❑Aquifer Recharge oundwater Remediation ft. ft.
19.'SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑SalinilyBarrier .FROM TO MATERIAL' • . EMPLACEMENT METHOD
❑Aquifer Test . ❑StonnwaterDrainage • ft. •• ft'. '
['Experimental Technology ❑Subsidence Control ft, ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach'additional sheets if necessary) -
OCieothermal(Heating/Cooling Return) (hel•(explain under#21 Remarks) PROM TO, DESCRIPTION(color,hardness sof0rock type,grain sizc�ete)
ft. S ft. 1
6.7 4.Date Well(s)Completed: Well ID# 25 ft• -+ ft y AA
5a.Well Location: ft. ft. /
/� '3C hauteJlourCJ vefsSyy.eR L.5 'c'J)0 Ye iy2/6`�g99q rt, ft. k__ ,+T - ,
Facility/OunerName FacilityiD//(if applicable) ft. • ft. _"a>-a.r; 1 ci� r'•4 ,
•212.7L Jeu,r,e /31v /17;er '
5014 -lie, 2.�5 Y
" ‘ ft. ft, �� t) t 20?3
Physical Address,City,and Zip ft, _Tt.
©IV5/f)U.) • 113 21.REMARKS IR; ,,, ._. �� ;a,• =4
County Parcel Identi �.eeCfer- �+' .�,fictuion No.(PIN) Crfl�It/ i✓$ pA,/�� OiC/
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: s'�e�'''r el S�h�'1^a E r for e,��srrctrY{+n n+r,j f'/e1, 1S
(if well field,one[Wong is sufficient) 22.'Certifieatio
7 if 4/ '77 w3 1
. -9. . jO•-:/e--2,3.
6.is(are)the well(s): rmanent or OTemporary • Signature of Certified Well Contractor Date
Bp signing Ibis form,T hereby ce,-hfj•that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [i1Ve • 15ANCAC 02C.0100 or i5A NcAC OK'.0100{Yell Construction Standards and that is copy
(fNds is a repair,fill out knoy'n well con.shvclion infwrnratiwn and exiilain the nature ofthe of thisiecord has been provided 10 lhearell owner.
repair under 021 rearm ks section or on die hark of Rtis form,
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23.Site diagram or additional well details: .
8.For Geoprobe/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: 4171 7 •
ft:) •For multiple wells list all depths rfdi/erect(example-3 rr 200'and 21 l00� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: le , •24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above easing,use"+^ ( ) information Processing Unit,1 G17iMSC,Raleigh,NC 27699-1617
11,Borehole diameter: G/o - (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(1UC)
Program,1:636 MSC,Raleigh;NC 27699-1636
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• l2.Well construction method: Id tc-L 1,✓1//C i ' •
(i.e,nu er,rota 24c._For Water Supply and Open-Loop Geothermal Return Wells;Copy to the
s ry,cable,tlircet push;etc.) county environmental,health-department of the county where installed
FOR WATER SUPPLY'WI'!LS ONLY: 24d,For Water'Wells producing Over 100,000 GPD: Copy to DWR,CCPC1JA
13a.Yield m Permit Program;1611 MSC,Raleigh,-NC 27699-1611
(gP ) • Method of test: .
13b.Disinfection type: Aniount: - i / •
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Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources, i Revised 6.6,2018

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(Go TER ISTD Heater BoringI Construction Detail Revision#: 0
Release date:5/12/23
• ,I Approved by: 5L
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((..--"') I
Well ID
H-42
Date 7-8---4?„7.
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0 I 1
Oversight Job# R23-104
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'td• V;12) erly I
Driller ri . 1
I
- Constructed
(fill out if
Design different) Notes
• --Stick Up Height .1/2"Thermocouple pipe? •••••,-, „, i 24" MI,
Thermocouple Length 48.67' I
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Ground Surface 0.0'
Heater Can Conductive HT Grout—C , .v Angle from Horizontal ' 90°
••- I
i ; • •
Schedule 40 ' • ) •1 ,
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t— Borehole Diameter , 6"
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l- -
11
. 1. ,
Heater Can Length 49 ft . ; ' •5 Gal Buckets of Graphite 12.5 1 '
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• ••'Bags of Silica 3.25 a
, , .
Heater Can Diameter 3 in .:• 1
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1. ' ' ' [Rags of Cement 10.75 q
.... .,
Installation Method - ..1 1
Direct Push , 1
,,..„
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Sonic •1 ., 1,- I
i• ,1
Hollow Stem Auger I• •
• ' ; •, 1
Mud Rotary
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Other: 1 I
A. i Bottom of Heater Can 47'
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• ' ' ,
• t
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1, ' ; '• : Bottom of Borehole 47' V77.....,
Post-lristallation QC(to be performed 24hrs after Installation) PID Log:Make/Model: I
1)Confirm well is free of grout Design !Constructed Time: Ility, , Reading: 40/ PPM
Depth to bottom of well(ft bTOD , 4q. 1 ' Time: i f 'ill ' Reading: eg PPM
if greater than or equal to lft less than designed alert the office Time: .1; ,0 I Reading: 7) PPM
2)Confirm grout plug reaches ground surface Time: I , Reading: PPM
repeat daily until depth to grout is Oft. Time: • I • Reading: PPM
Date • Depth to Grout(ft bgs) • Notes: ,
i , 6
tery), v 1
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