GW1--07027_Well Construction - GW1_20231102

WELL CONSTRUCTION RECORD(GW-1)
For Internal Use Only:
I.��)Well Contractor Information:
us"/1t GL-/+1 id t Mh>er I 14.WATER ZONES
Well Contractor Name / FROM TO DESCRIPTION
Q 76
A ff. ft.
NC Well Contractor Certification Number rt ft.
15.OUTER CASING(for multi-eased wells)OR LINER(if ap Ilcable)
1.•Lit..-1 C Ct„ei e 2.)r/ /h n/3 FROM I TO I DIAMETER THICKNESS MATERIAL
Company Name ft. ft. in.
/� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:ipA CL/ C L f'1 S•J.e FROM TO DIAMETER
List all applicable well construction pe nits(i.e.1/1C.County.Stale, Variance.etc.) ft. THICKNESS MATERIAL
List ft. in.
3.Well Use(check well use): pc'ri►+/ fi�J 4✓a:Y e to -- _.-._
ft. ft. In.
Water Supply Well: 17.SCREEN
❑Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
ft. ft, in.
❑IndustriaUCommercial ❑Residential Water Supply(shared)
I8.GROUT
Obligation •
❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: /�� tt• ft.
DAquifer Recharge ,17C,roundwater Renfediation ft. ft.
❑Aquifer Storage and Recove 19.SAND/GRAVEL PACK(if applicable)
1y ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stortnwater Drainage • • ft. ft.
❑Experimental Technology ❑Subsidence Control ft. rt.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOC(attach additional sheets if necessary)
Cher(explain tinder#21 Remarks) FROM To DESCRIPTION(color,hardness,,snlVrock type,grain ttac.etc.)
❑Geothermal(Heating/Cooling Return)
o ft. 2.S ft. s ct _L
4.Date Wells Com Ieted:It�)" "Z ,/ -lr �1)rip®�'� /f'6`�Sri ry CT C
() P Well iD# y _ / 2 S ft' iv •it.
a ry �.,.�r'fZ-raivtQ
5a.Well Location: ft. ft. --
/Mt orn)4 our C1a.,l,tef R. S e 4(c.1)d�16 yyy9y rt. ft. -
Facility/Owner Name Facility 1Dli(if applicable) ft• ft
2 iZ7 Z e„d.e i31VG(lit a.ers•ON✓�-1/e, 28.E 'y ft. NOVJ
2 2023
Physical Address,City,and Zip ft. ft. •
ON-5/0 u) 4'314'13ay7818 221.REMARKS -
County Parcel Identification No.(PiN) V,,o c r-L-- 'fr6T tI O Ad Aka
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 5t►e�, eAs��► ^a-�t 10 r e�.�sr�we fir iv c�!�Ca i�S
(ifwcll field,one lat/long is sufficient) 22.Certification;
31,711l4/40 N - '7.7,. 3dId 00 W 4/�� ://,,,,
6.Is(are)the well(s): llrmanent or OTemporary Signature of Certified Well Contractor Date
By signing this form I hereby certify that the we/!ls)was(were)constructed in accurdanee with
7.Is this a repair to an existing well: ❑Yes or NlIVo 1 SA NCAC 02C.0100 nr 15A NCAC 02C'.0200 Well Construction Standards and that a crept
if this is a repair,fill out known well construction in/brntatio n and explain the nature of the of this record has been provided to the well owner.
repair under IQ!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/OPT or Closed-Loop Geothermal Wells having the same
(add'See Over'in Remarks Box).Youmay also attach additional pages if tfecessaty,
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells
drilled:
` 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / ft.
For multiple trees list all depths ikdi(/exam(example-3 r@i 200'and 2©100') ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: IV (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level t:c above casing,rase"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: on.) 24b. For Injection Wells: Copy to DWR, Underground Injection Control(WC)
,t._ C Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AOf eL S drvI L
(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 m Permit Program, 1611 MSC,Raleigh,NC 27699-1611
(gP ) Method of test:
13b.Disinfection type: Amount: -
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2n18

y44 iERRATHERM VEIN Boring Construction Detail Revision#:_1_
Release date:_6/27/23_
Approved by: EH_
4111) Well ID V-i 1) 3
�{ Date •_ • Z.
Oversight ` AILL'l4)5 Job# R23-104
Driller C--• C R.11`ht-t►t✓/l) V-AiLeely
Constructed
(flU out If
Design different) Notes
N
---VEW Slick-Up Height 18" r "^ [a,
Ground Surface 0.0'
Conductive HTGout—
Angk from Horizontal 22'
Borehole Diameter 6"
Top of BOO Sand 13.5'
Top of Screen 26.5'
1 5 Gar Buckets of Graphite 1
Riser Length iet ft Bops of Silica 1.25
11110 Screen Length 15 ft
Screen Dlemter 1 In Bags of Cement 4
Bogs of B'00 Sand 9.5 f(
installation Method Gallons of Limestone 9.5 L "
I. - ' sh
Hollow Stem Auger -
Mud Rotary
Other:
Bottom of Send and Screen 41.5'
Bottom of Borehole 41.5' L'il l
Post-Installation QC(to be performed 24hrs after Installation) PIO Log:Make/Model:
11)Confirm well Is free of grout Design Constructed Time: (IN'Lk,t) Reading: 0.0 PPM
1Depth to bottom of well eft bTOC a9 ft Time: \01.4 Reading: 0, PPM
if greater than or equal to Ift less than designed alert the office Time: \V\ v,6 Reading: D.0 PPM
2)Confirm grout plug reaches ground surface lime: Reading: PPM
repeat daily until depth to grout is Oft. Time: Reading: PPM
Date r Depth to Grout fit bgs! Notes:1:j,0%Lt. c, C,,� ua —1-1,-Z.,3
TR ti CA, i i w% 14Eit--'1/4—SC.IUEC-A) T.
M*-- (^tN ' ?.