GW1--07025_Well Construction - GW1_20231102

WELL CONSTRUCTION RECORD(GW_1
For Internal Use Only:
1.Well Contractor Informations: I
l(,vr/fit 4 /v% /dt Mlaer I�,/
Well Contractor Name / 14.WATER ZONES
FROM TO DESCRIPTION
3$ 76 11 ft.
NC Well Contractor Certification Number fit fit.
//�� 15.OUTER CASING(for multi-cased wells)OR LINER(if an Ileahle)
/s 0-.5C C�.ct e. !Jr/ it Af:9 FROM I TO i DIAMETER THICKNESS MATERIAL
Company Name it. rt. in.
2.Well Constr uction Permit#:r /9 CLRC 1.- 5;.f C 16.INNER CASING OR TUBING(geothermal closed-loop)
List all applicable well construction pe nits(i.e.UIC.County,State,Variance,etc.) FROM TO DIAMETER THICKNESS MATERIALfit. ft. in.
3.Well Use(check well use): Per-A,/n/#% Id a•. re rQ
ft. ft. In.
Water Supply Well: 17.SCREEN
°Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Municipal/Public ft.
❑Geothermal(Heating/Cooling Supply) °Residential Water Supply lc IL In.
PP Y(single) R. ft. In.Dlndustrial/Commercial ❑Residential Water Supply(shared)
°hTigation OWells>100,000 GPD FROMGROUT TO -
Non-Water Supply Well: MATERIAL' EMPLACEMENT METHOD&AMOUNT
ft. ft.
°Monitoring ❑Recovery
Injection Well: /�` rt. ft.°Aquifer Recharge I1)6" ndwater Reinediation fit. it. •
°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
fit. it.
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ther(explain under#21 Remarks) FROM TO
DESCRIPTION(color,Mrdaeaf roll/rock type,gain skc,etc.)
r ft. ZS fit. T,J/t,,r�jtdOi°i�r'�`�3(�adC�CjdC`/
4.Date Well(s)Completed:/O'"'3"�,� Well 113# bt`-0 1 L- 2 S ft. 77) � -6... -() I
ray 4u�fZ S0./v[X
Sn.Well Location: f• ft. /
Mk. OiVe-PourC ,vets sie {iwl_ sie 4i warier/99y ft. it.
Facility/Owner Name Facility!DU(if applicable) ft. ft. jj -
,'•1',/ ti 4) i'1 r ,
J
2 f 27 rVev.ve /31i/6 X.eti5e,Iv"/1ie. 2 B.'SIG ft. ft.
Physical Address.City,and Zip ft. ft. ----
O.v-5/0 Ltd1/3 36W3D10818 21.REMARKS -
County Parcel Identification No.(PIN) ✓7'eeK ` Pr L/•OLi✓c. r Q r Exi .{•f'O...., Werl
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: See-A,ttiodl eds'chepn,-.i-t. for C a.frsfror[tag,w•ej elo.4 Li(if well field,one lat/long is sufficient)
22.Certification:
3y•7yl yeo N - 77, 3dlI as
6.Is(are)the well(s): rmanent or ❑Temporary ignaturc ofCcnificd Well Contractor Date
7.Is this a repair to an existingwell: °Yes or ,��' By signing this form,I hereby certij•that the mell(r)was(were)constructed in accordance with
1111 t ISA NCAC 02C.0100 or 1.54 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the tie owner.
repair under#21 remarks section or on the hark of this fortis.
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
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 76 • S (ft.)
For nudtiple wells list a/I depths if different(example-3(§200'and 2e1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: /6 (fit) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing.use'+�f Information Processing Unit,1617 MSC,Raleigh,NC 27699-I617
11.Borehole diameter: / (ill,) 24b. For Infection Wells: Copy to DWR, Underground Injection Control(lUC)
/� Program, 1636 MSC,Raleigh,NC 27699-1636
!7
12.Well construction method: /1 f0.�d•ele i C.
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCIJA
13a.Yield Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gpm) Method of test:
13b.Disinfection type: Amount: -
i
Revised 6•!,.)n t a
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources

TERRATHERM ISTD Heater Boring Construction Detail Revision#:_1 _
k. Release date:_6/14/23_
Approved by:
--" Well ID HC-04E Date (i:, -- i g 4 ` 33
Oversight ``. .. 63 4.^. h lob# R23-104
Driller C cn ) K 1r n�j(2Idj►,�iert�,
j Constructed
(fill out If
Design different) Notes
--Length of Can Stick-Up(ft)/
Height of Can Stick-up Above
1/2"Thermocouple pipe? Ground(in) 5'/30"
Thermocouple Length 77•29' -Length of VEW Stick-Up lit)/
Height of Riser Stick-Up Above
Ground(in) 1.5'/6"
Ground Surface 0.0'
Heater Can Conductive flrGrout— 111_,
Angle from Horizontal 22"
Schedule 80 a'
Borehole Diameter 7"
Top of#00 Sand 21.5' )!
Top of Screen 26.5' Q a t io t t
Heater Can Length 81.5 ft S Gal Bucketsnf6,opiate 2.5
---"°‘ Heater Can Diameter 3 in Bogs of Silica 3.5
Screen Length ii4) a ^8'' ft Bags of Cement 11
Riser Length 29 ft Co ' a
Screen Diameter 1 in .......
Bottom of Screen 34.5' e
,
Installation Method
Direct Push Bags of MO Sand 15
Sonic
Hollow Stem Auger Gallons of Crushed
Mud Rotary Limestone 15
Other:
Bottom of#00 Sand 61.5'
Bottom of Heater Can 76.5'
Bottom of Borehole 76.5'
Post-Installation QC(to be performed 24hrs after installation) PIO Log:rMake/Model:
y
1)Confirm well Is free of grout Design Constructed Time: ' i 34 ctryt Reading: Cl,Q PPM
Depth to bottom of well[ft bTOC R1 5' Time: / , 3Qy_�.-_ Reading: Q rg PPM
if greater than or equal to Ift less than designed alert the office Time: M0 an,, Reading: Q/ PPM
2)Confirm grout plug reaches ground surface Time: Ciel4rn.... Reading: 0 r. JJ PPM
repeat daily until depth to grout is Oft. Time: a;3 Q l fi-A Reading: 4,r/7 PPM
Date Depth to Grout[ft bgsj Notes: /