GW1--07010_Well Construction - GW1_20231102

WELL CONSTRUCTION RECORD(GW-I)
For Internal Use Only:
1.j )Well Contractor Information:
(fi I
i
r/lld-rN We e t
t4.WATER ZONES
Well Contractor Namc FROM TO DESCRIPTION
NC Well Contractor Certification Number ft. ft.
/ 1S.OUTER CASING(for multi-eased wells)OR LINER(if ap Ilcable)
CO..SC C.4 e br lb i✓4J FROM I TO f DIAMETER I THICKNESS MATERIAL
Company Name
it• ft. In.
2.Well Construction Permit#: 16.INNER CASING OR TUBING(geothermal closed-loop)
A t-L 1 C L.r 1 JLe FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction p its(i.e.UK'.County,State,Variance,e etc.)„ ft. R. in.
3.Well Use(check well use): Peer•,ifb~9 W et-' +r H
ft. in.
Water Supply Well: 17.SCREEN
❑Agricultural ❑M FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
unicipal/public ft, ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
ft. ft. In.
°lndustrial/Commercial ❑Residential Water Supply(shared)
°]rrigation 18.GROUT
Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery _
ft. R
Injection Well: •
//��
❑Aquifer Recharge �dr•Ldwater Remediation ft. ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(if applicable) •
FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test ❑Stormwater Drainage • ft. • ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) then(explain under#21 Remarks) FROM DESCRIPTION(color,hardness,soil/oek type,grain size.size,cu.j_
TO G J D ft. 2 S. ft. .,,(�.401/ rh obis r of 3a.N1 U'tv_1 arl 4,Date Well(s)Completed:i "D - Well iD# N / Z 2 S rt. 7.7 ,rt• 1 _�)
LJ /'fS�1 a nr12.�0L/v i�
5a.Well Location: D. It. / -
/3BC.' O/e-}iour CIS 4,e(x refu , -S,/e /ir A 02.16 Yy99Y ft. N. _
Facility/Owner Name Facility ID#(if applicable) ft. it. NOV ) )
2/27 t jetli.e /3/1/6.T err eA/W;i/ef 2 8s•Sid R. ft.
Physical Address,City,and Zip it. ft. ,.-'--'
00V-5/0w y3 1/3D1/78 18 21.REMARKS
County Parcel Identification No.(PIN) / Tel- 00.-a.'�N..s:&//,,.-f-,O_ _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: S•e A'b�1 eische_/no-'E-t`c.for C t%M 1j r f-'a w d e tc%i is
(if well field,one lat/long is sufficient) 22.Certification:
3ti.7y/4/00 N - '77, .3dlivD /
6.ia(are)the well(s): tBPermanent or ❑Temporary 23
Signature of Certified Well Contractor rta~~4%CC /
DAte
By signing this form,1 hereby certify that the wr//(s)was(were)conraxaved in accordance with
7.Is this a repair to an existing well: ❑Yes or Q11‘ 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
lfthee 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 hark of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2.. (ft.)
For multiple wells list all depths if different(example-3(a�100'and 2@1011) Submit this GW 1 within 30 days of well completion per the following:
10.Static water level below top of casing: 49 (f 24a. For AD Wells: Original form to Division of Water Resources (DWR),
(Twofer level is above cashing,use"+ t) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
,p e� Program, 1636 MSC,Raleigh,NC 27699-1636
/1
12.Well construction method: O 1�0.SOW 24.For Water Supply and Open-Loop Geothermal Return Wells:Co to the
(i.e,auger,rotary,cable,direct grub,ere.) county environmental health department of the county where installed py
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCl/A
13a,Yield m Permit Program, 1611 MSC,Raleigh,NC 27699-1611
(BP ) Method of test:
13b.Disinfection type: Amount: -
Revised 6-6-701 ti
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources

IWO TERRATHERM ISTD Heater Boring Construction Detail Revision#: 0
Release date: 5/12/23
Approved by: SL
Well ID H-12 Date
Oversight .. V t1 Job# R23-104
Driller Fe eJ +5/7� ,,,,dam jy
Constructed
(fill out if
Design different) Notes
--Stick Up Height � '
0�
C,
1/2"Thermocouple pipe? \ _;" ; . 4 24" �
Thermocouple Length 27,67 _--
Ground Surface 0.0'
Heater Can Conductive HT Grout— Angle from Horizontal 90°
Schedule 40
Borehole Diameter 6"
Heater Can Length 28 ft 5 Gal Buckets of Graphite 1.25
Bags of Silica 1.75
Heater Can Diameter 3 in
Bags of Cement 6
Installation Method
Direct Push
Hollow Stem Auger
Mud Rotary
Other:
Bottom of Heater Can 26'
Bottom of Borehole 26' act.
Post-Installation QC(to be performed 24hrs after Installation) PID Log:Make/Model:
1)Confirm well is free of grout Design Constructed Time: Reading: PPM
Depth to bottom of well(ft bTOC 711' 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. Time: Reading: PPM
Date Depth to Grout[ft bgsj Notes: