WQ0037555_Well Construction GW-1s_20230201

WELL CONSTRUCTION RECORD GW-1
1. Ws lI Coariraetor ltforinaliou:
For Intemal Use
Michael Patrick, Jr.
WeLI Cwmm= NA=
44 -
N(' WClI ('cmtcxlorCcrtificattm:Nwinkxr
l}/ltLW Drilling, LL
eefflvdii.y Nam*
2. Well Construction PErMit ill.
LfalaK aAKr-mtk muff colA emmim pernlfft (.c UIC, CawW. Stwe. varravcc, ric.)
3. Well Use (check well! used
Water Supply Well --
Agricultural []MUslicijXMUbhC
Cleo herrna] (IAC86ng1Coaltng Supply) [JRCSidetltial Water Supply (yinoo)
1nldustrislli2wnmer6al DResAentlal WateT Supply (Sh")
Itlcn
i Nom-Willer Supply Well,
Aquifer Rccharge
Aquifer Storage and Recovery
Aqultcr Test
Expoimental Technolog}+
(iaathurnal (CIMW LJovp)
DCrtundweber Rbn1edL1A1011
[33-linity Barrier
Dswmwster ❑ffl=ge
1391,b36MWe Ccmtral
Tracer
ila in under ir'21 Reynvk%
4. slate Well(s) Compkted; 14- 6- Web 1D# ill 1
31 . WeU I "fipn:
TdIlium Links & Village
Feta1iiw0% uer Maine FeciGty Off (ilaWllraVc-)
48 Links Drive, Cashiers, NC 28717
Prpsoeal A*d ram,C 11y, xnd f.:
Jackson
Cotmry
Parcel Ide.ftr,ratmn No. (PIN)
5b. Lmitade ind loagilude in or decilrtol degrees'
(,FWell Held. nee l IMS iS Edf LiC100
35.14362952 K-83.13572922
6. la(are) the weD(s)�}x Permanent -or E]Temporaxy
7, le this 4 1 kir too *kI pti8dxIg well: [3Yn or ONo
ff JhA IN fJ rPWMF, frr1i f11N wrT{ PF�4+ Cf1R5'&MffWM hVarN DrJf'!r! Md rtJM fhe lr( lrrd Of the
.,rp„iry kr-2irsswnUaaerkwrewtrhotwatVAfaforai.
$, ForGeoprobefDPT or C_losed-L.00p Geothermat Urells having the sarne
03risbYUCtiQA o311y I GW-] is [seeded lnd=( gTQTAL MLIMBER ofwelIs
drilled:
9. Total Well depth below land Wrfaee: fdU
Fee mwhWe 1Fgfi Arr aft akplhs Jj &JgfeFem feAam pla, 3@2W' ¢m 2(Q10J?
10. Static watsr kertl below top ofcming:
{f barer lm, -1 u ab," GriRW& 4w "-
1 L Borehole diamckr: 6
12.Weklcuualructi&Nmethod: Sonic
{LA ajar, rosary, cable- dire= push, ere )
14. WATER
7Ai+M
PROM
To o {i1lPnnrJ
R-
fit.
R
fr,
YS OCITERCASIN(; for inu W- Casad wdFa OR UN ItE kdhte
kROm 'nl ulArr78TP.R TAK;KrCES9 MATLMAL
ft ft
in.
Lf. INMER CAMG OR I'L'BING f rlrthrrmaI rlum l-l1 h
FRgM
TG
DLi3}r,IF-H
III11'KhLsn
MATPJkLiL
fa
35 irL
2 "''
SCh 40
PVC
1k
tL
11, S RF.BN
FROM
-10
nLiMYI'iA SLATSHE
THDCKN IS
MATERIAL
35 ft-
55 fL
2 im 0.010
Sch 40
PVC
%
R,
is
1& CRoLrr
FROM
TO
MATriRlhr.
1NPLACEMENT MEULOP&A.t10Uf'JT
0 fL
27 n-
Portland Cement
Trerrtie
27 ft
32
6entonipe Chips
Pour
iB-;;i.Nn,RAYfLPAC K Ifo Heable
prt(5,rr
TV
MATERIAL
EMPLACTF4rNTRSLrnCho
32 ft.
60 ft�
02 Medium Sand
Pour
It
fti
21). I)KlLLIKG LOG qatu
addktlonakstlae#ifnJ sa
FROM
74
DF9CRI1PT[OF jular.ha.,lupry Ura&1 y emln.ecaP
ft.
fL
ft-
fL
Ft.
fr.
ft
rI.
ft.
h
fit.
FI.
fl-
rl.
Tir L7CMiARICR
21 certification:
V /Nil
93PLULre ofC*rtjfW Well contracbm
11-9-22
UWX
j4r-OK nx flr& f4rr11or ) A L"by rnNfp &W the ralf(a) wax tMVV mp onrow W Jrcow e
Kira, 1SA XC.{C 02C .01M or 13-4 r CAC 02C 02ri0 Wd1 CCnnshveA=Mwrdareh 8md ihm a
cyfy .k rhrx Fvcn d hat fh' A rJ JdZd fa f& 114f ONM1k'F.
23. Stir diagram or addltiooal well delifils:
Ysnl may use the hack of thLs page Lo provide addktiorW well site details or vml I
congouctinn detalks. You may also attach addktionel "it if txaessiry.
SI HM1'i'VAL.IM1SMr:C-11
ittl 2U. For Ali Wells: Submit this form withm 30 drays of camp]ntiau of yell
crmwuctum to the follcvwin&
(ft-) Division ofWater FLesourrez, larormatilm Proeelains. (fin it,
1617 MAII Scrvkx Crater, Raldgh, NC 27699-1617
24h- For Lniecon wells: In addition to scalding the form to fhe address in Ada
above:, also submit one copy u* this form vnthin 30 days art` completion of well
cori%tmctlnn to the folk wv4'.
Division of Watrr Resources, Undergrornd Imjmtian {Control Program,
FiDR WATT1R SGPPI N 44rLLLIi ONE. - 16A Mrtil Se"Iet Center, RaLeo, NC 27699-143b
Lair YiOd (gpm) licthod of test• 24c- For Water Stpppb' & Lnmccdo■ WOW In #d4irion In tending t1le form to
the addre*cs) abwr, also suhmit Dole copy of this form within 30 days of
13br DiainfevOun type: Amount: completion of well cowtmat1on to the county health department of the county
whine ecrostructed .
I-Orm GW-L Plar111 CnralLnu DgWirtmoll. af.En%ieorumbral Quality - INvigLoll 4rWJnCr Rep(m=m R-v4W 2.22-2016

WELL CONSTRUCTION RECORD (GW-1 �
1. Well ]contractor lnfmrmutiae.
Print FoTM
ltlteniw Ilse
Michael Patrick, Jr.
Wall Conuamr Nr
44-
NC Well Com um Cc6ficetion NuffbW
M&ill Drilling, LL
f Gmperiy Nalnc
2, Well Covslrucuo■ Permit#:
l.ur c�Y appdicabke rrdl Gontrrucir. l pemNfs 0 ff UJC, Caam% SYala. VorlwNw, ex)
3. Weil i]Lc (check wrl use);
1N5tler Sti Weu
Agricultural
[ jMunicipAVPuMJC
ieotElerrnal (HmtingJCoaliltg Supply)
[] KesRlenual Watu Supply (single)
IndustiaVComrnerciai
13ResidenWl WatEw Supply (-hamd)
IrriaaTion
Nqm-WeterSrpply Well:
M ( (MitCQnlg
R Dvery
Jm.ieetiae Well:
Recharge C)Ciraundwater RcmeriiAtim
swage and Recovery 13Salln,ty Barrier
Test [39tortnwater I}raitiage
Ienfal Technology [ISubsidefice Comae]
Ii111. (Clowd Loup) C)7rucar
loin udder #21 lxel mks
4-'hate Wells) Completed: 10-27-22 Well TDN M -
5a. Weld Location;
Trillium Links & Village _
Faratit W0wrr,g Naive Fscillry IDA (zfnppl.cehlr)
8 Links Driver Cashiers, NC 28717
Roml Address, tsily, Vid
Jackson
C%U"
Identii'iueon No. (Piro)
5b, l..aOtude and lonlgitede in degrecOhimntesfwnilds or deeinlal depreea!
(lfwca field one IRVIur;g is sutlfcimd)
35-14466462
rV -$3.13669127
t;_ ls(are) the w, ell[ejap"inaReee or OTemporary
W
7- is this a repair to aY exisiling well-' []Ves or EiNo
1f riles fs er repufr. fit ouf knotty, va8 s rrwj!i iRomwBWAfm awl d*aix the rtawre of rho
FC fa?T Wdcr r 2f jrwaFhx sea mN OF ore ehe brick of rhle form
& For Geaprobe/DPT or {lowed -Loop Geothcrmai Wells h$vblg the semae
cDmtractian, only 1 CW-I is beerier] ind ioate TOTA L AIUMBER of wells
drilled
9. Total well depth below land surrace- 74 (FL)
m r ,'ange "us Ilse W1 Qvrht OrAOrrnr (crmrgalc- JQ"' mrd 2@iR)
s#- Matic water Jcvel hrbarw top of emiog;
f f muter 0,.,W a a#x)vr. as Arq, m�e
11. Borehole dionleeerl
17- Well eomstruc#ion method; Sonic
(Le. nw+, mt y, eAk. ditca pwb. M.)
(lam)
14. W vfER ZONES
62CHM
TO
d1xW
ft
fl,
ti
il.
15, OU'MR C'A51MA Ow multi#eyed wrells GR LINE if ir�lrlrt)
PROM
1+Q I}IAhTl1'ER
'IIIICKNT;s5
Mh7r�RLlL
rr,
ft in-
lb.1FiNSR CAS1C+iCv OR T•L+RSfYf, l emhero�I elntd�o•
yl QM TO rilhMF TICK THICK_'IE58
S CEltlkl-
tr. 36 R. 2 io SO 40
PVC
fl. ft IN.
t7.9C71£EfY
FHOM TO I
DLSM€ R
I SLIVI'MM
1 T,H.,LI.C,IQIFSS lgA7'RR[a[.
36
2 l°
0.010
ch 40 PVC
ft iL
i
15. GROUT
FRIGM
TO
MATIMAL Eh]PEA{FMTW M WMI)h & AWMr
h
26 R
Pauiiard ctr1 nt Tremie
26 tL
31
Beirflr0a chips Pour
Il,
ffi
IB-$AND/oRAVELPAC
K t" lieeiblc
mom
TO
HAIERLILL
ErdFIACRMkhri'MErFrOD
31 k
70
#2 Medium Sand
Pour
ft
ft_
20, D]FULLa
G LOG fsiM nddifulmIIF its if FUM HM
FRM
Tt}
nRti[7IIP316r, eam. hmd fd4iwk even -i� 440
{�
it
ft
R-
fl.
rtr
fl.
ft,
fr.
ft.
21- R1IMARVS
22L CertificaHOm:
Sig=hac ofC4rd6cd Wd Cow+�dr dais
Ay nWriag Chia jfartn, f Aeredy+ cerr* f W adr tacos (wLc cdvwt read fa rer�Phoz*w
WA 15A WAC UC' oleo ar J3d MW jK- 02r .j?20R IYrlf Camtj"Cornm S4Q+,dar t a,rd rhar a
copy of duo ta&>fd A= beets prar"M ro AW wd, mvWr.
23, Site dhlgra rx or additional well detwlilL
You nlay use the hank of this page to provide additumal weJ1 site details or well
aonstruclion details. You Inay also Mach addrUnnat pages Ifnnuessary-
SURI I.ML INSTRUCTI(]IY4
24a. For All Well Submit thu form wittun K days of complatwri of well
cor►stneation to the fallov 1Pg--
4) flbvisins of Water Reumreea, InJtofMAdeD Processing Unit,
1617 Mail Service C enter, Rateigk NC 2709-1617
241yL Far 11 iettivn Wtila: In additiaa to Sending the from to Nee address in 24a
above, also submit one oapy of this farm wuhin W days of compli tion of wolf
cons mctiun to the following:
Division of Water Resomrom Undrrgroead Enjectioo Covirol Program,
FOR WATER SUPPLY WELLS UNLY: 106 hail nervier [`.rater, Raleigh. NC 27699-100i
13a. Yield (rpm) MetMd of teat 24c. por Watcy Supply & fa ectior %AeHs_- In addition w nmdinig *e form to
the addTC55(cs) above, also submit om oopy of they farm within 30 days of
13b. DisinfNtiou type! Am6mnt-. completion of well construcmcn to the county henilh deWment of the ooeo7ty
FommGWA NaalhCwWmaDeme[meet ofGovirun■ ntal Qmhty - DMsiao of W4 tw%Amurom Revmtil 2-32-2016

WELL CON STRU CTION RECORD (GW-1}
L WC11 COntraet4T lnformwfioo;
Michael Patrick, Jr.
Well Co=actor NaTx
449 -
NC W01 Corwulcr {;Crhlicnhnu hiur.Isa.
&W Drilling, LL
Company Name
2, Wtll COASIracfior Permit fi:
Lftr4R WfOWN9 well6WLP'mwrKw(mrmres4k. M 09nrY. Sftm. Yuriwcir, rrc)
& WO Use (check well use):
Goothemtal (HeetinWoahng Supply)
ndusLria1 CMmeftial
Non -Water Supply Well:
Aquifer R e*Tgc
A.qu i fer Storage and Rmaveay
Ayuitr Tc5t
RxpcijmcnLal Technology
Geothermal (Cngcd [Annp)
MlunociPW%blio
[]ResLdendai Water Supply (single)
OResidendalWat SrS ly(shared)
0GroundwK,T ki=ediarion
0Sallnity Barrier
DSuxmuHLer D OrMW
MSubsidence Control
DT.
tlyder 821
4. Dw Wells) Completed: 10- 7- 2 Well 3iT1 M Y _
50, well Lacotion!
Trillium Links & Village
Facility++dwoerNema Facilq TDB (ifafplicablo)
48 Links Drive, Cashiers, ND 28717
T'1Lysi"i Addnss. Ciry. and hi,
Jackson
{ aalypy
Parrml Ldw6 "ion \b. {T'[N)
51b. Latitude and WiWt■d(, in {legmeshninumilseconds or decimal degrees,
(ifw b field. one hi long isguffimmki)
35.14420257 N-83.13738535
C ls(are) tie well(S) Permanent or Temporary
7, Is this s repair to ao existing Md1! Yea or EjNo
fffhrr rF 47 roy afr, fief ma fmaxvi ,roll s rruerirw i;oh-mawian amde.Tpfuilr Ae nanum ofoh*
repulr nrtder i'21 rennaykx aecrlm or n@ the 40a qfrhu fNM.
8, For Gwprob&DPT or Clomod-Loop Geothermal Wcfls ldvirg the Berme
ComS nlCtion, only 1 OW- L is nimd1ed. Ind icate TOTAL N UMBER of wells
dolled.__
9. Total well depth bcluw land surfkee: 60 VQ
Fnrmulryil "41s1rsaulldvrkx,fd&rmr (x'ampk-3 - w)
1-0. Static water F" below tap of casing:
jyNw rfargfarra5awe Tjrg,
a1, 8orehr14e diameter 6
II Well C*omtructiion mathad: Sonic
(i.e. AVVX, nThWy, mbk. dm U puAi, ale.}
Or'.)
14. WATKR ZONES
MM
TO
I dESCI[7MN
n
tt
n,
ter
13 OUTERCASINGigrmulL>�ra11s (k1xLIN8R 'f a31a
FROM
TO
antrrSK� ea
THICKNESS MATtiR1AL
iF I
A.
I in,
IC ] KNER iUA' 1ING KI" 1HFNG lhWENl elased-loo
FWN
1V a[amlcrE:a im00;uSS
MATMAL
D rL
25 ML 2 '" SCh 40
PVC.
ft
f.
17, SCREKK
T4
ULaathrFjt
SLOTSdF.E
Tt WKNESS
MAT4RIA1.
% 45 tt
T
2 io.
0,010
Sch 44
PVC
18. GROUT
FROM
TO
MAIER1Al
1MPLA MENrMETHOU * ANQV9T
0 fL
18 �`'
perdmw comes
Tremie
18 ft
23 Ft'
Bent;anits Chips
Pour
50 fl'
60 ft.
Bent. Chips
Pour
I9. S NA%;RAYLLPAC14 i(2 iemble
FROM
TO
Mh7YlSlhL
RMFLACfMV rrNFrH u
23 r'`
50 ft'
#2 Medium Sand
Pour
n,
n.
24. D R I L L i m G LQ6 ■liaeh aairdone1 sheets if w-Tt,mi
FROPA
T4
UffiCBIPTION CriidvF, bnrdn� &Wewk Ir slxe,ate.
ft,
ft-
ft.
fA
f.
fL
ft.
ft,
F.
n
ft.
21- REMARKS
21 CcrtiiieatioO
Sl mwre ofCeltlfied Welt Coaaactar Duet
Uy mi riimg theT fiHur, I Aen4y oerr ' rhar jIm vd1f2/ wim (Wrm) e"isrrar.W IA x vra&m
�iA 15ANCAC 02C () lied or J5A NCAC n2C .02W Weil omd rhm o
pgrygfAib; nR4n+'i{Jb¢r been pwrirdrdfu aloe Keflarwlmr.
23. Site disgnim or 8dditionnl well detailir
Yau may use Lhe bade of this page to provide: 6dditional uel I site d[LaLIS or rvdl
construction details. You may also atiechadditional pages II`nommary
SUBMITTAL INSTRUCTTOI S
24iL For All Wells, Submit this Herren within 30 days of complctinn oT well
cow(tuCtlon to thefpllrnving:
VO Divisio■ of Water Reamrccs. Iuiormation Prmessiag Uait,
MI7 M1itlil Service f,:entm, RaLcighrNC 276994417
24L For li iertion Wells, Tn addition to sending the farm to the address 1n 74a
about, RISO submit one Lwpy of this form within 30 days of completion of wel I
construction to the following:
Divisinn of Water Rp murees, U ■dcrgrauud Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1635 Mail Service [:eater, lUlrigh, NC 276"-16M
13a, Yield (Rpm) Method of test 24e, For Water Sr 11* & Talleetion Wells, In addition to sending the farm to
the addresses} above, eiso submit one copy of thl5 frlrm vrithin 30 days of
13b. Nsinfrctiou tvpt, Amgnnt< wrnplction of wr.11 construction to the County hedL#h dep$LtmenL of the a mty
VAKn C4nRtr ntEd.
Form CW-1 NorthCluoLir DepnrhnentnfEmvmsmmmnle]{m6ty-LhvisionofWaierRcsatsrcce Ltev6ed2-22-2016