GW1--07028_Well Construction - GW1_20231102

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Wr/'id. jvl,b,il Mber I 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3 t$ 7(3' A ft. R.
NC Well Contractor Certification Number ft ft.
/�/fi 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
/�LN-5C cL.ci e r, /r/n/DJ FROM I TO J DIAMETER THICKNESS MATERIAL,
Company Name tt• ft. In.
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit Jl:
A L Ll+t C L I l �•f e FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pe its(i.e.U/C.County,Stale,Variance,etc.) It. IL in.
3.Well Use(check well use): Yer�r///Ay 64)6...; lee ce
n. ft, N.
Water Supply Well: 17.SCREEN
❑AgricultIU'al FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public ft. n, in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
ft. ft. In.
❑industrial/Comtnercial ❑Residential Water Supply(shared)
❑1rTigation IS.GROUT
❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well: ft. R.
❑Monitoring ❑Recovery
Injection Well: /�` ft. ft.
•
❑Aquifer Recharge 1:06 ndwater Remediation ft. ft.
❑Aquifer Storage and Recovery • OSalinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage • ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. '
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) then(explain under 021 Remarks) FROM TO DESCRIPTION(color,hardness mll/rock t pe,grain sixc,etc.j
4.Date Well(s)Completed://l '-'..2 = Well ID# 7.. •
Sn.Well Location: ft. ft.
/ABCO e-PiOur CleoWerSSIVertml-S-/e //eno2 6 q9 q ft. R,
Facility/Owner Name Facility 1Db(if applicable) ft. ft. -
2/Z•7 Z f eu�A-e /3/v Tact,wd-ilet 2 6'.5"V 6 ft. -
Physical Address,City,and Zip ft. ft.
ON.510 L.0 113 W`/301(78i 3 21.REMARKS1 �1 -
County Parcel Identification No.(PIN) AVE1i tx•[i!re eLwet./'-'e 3-S'e✓,"t_'/1; vi;l ii..i.. ,(�.'':
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: gee*,fr e/zch a4t`Lie r e tl v.SfrotC'Now et ).j Ss
(if well field,one lot/long is sufficient) 22.Certification:
3L/ 7Lr/ 1100 N ' 77. 36dd00 w '
6.is(are)the well(s): (Dt�ermanent or OTemporary
Jo-,/s2-23
tgnature of Certified Well Co ractor Date
By signing this form,I hereby cerlif•that the neH/.c)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Q1V0 iSA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
if this is a repair,ill out known well constriction 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
construction,only 1 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: 67 (ft.)
For multiple wells list all depths if different(example-3@200'and 2Qa l00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: /6" it) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+" ( 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 Program,1636 MSC,Raleigh,NC 27699-1636
/1
12.Well construction method: 0 fd.-SOW,[ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copyto the
(i.e.auger,rotary,cable,direct push,etc.)
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 27699-1 61 1
(gP ) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018

i TERRATHERM Temperature and Revision#:_0
"" Pressure Monitoring Point Release date:_5/12/23_
Construction Detail Approved by:
Well ID T-5 Date 0 "' gti "''" „
91119
Oversight A..,vJ Job#R23-104
Driller j G , {-,?/)(',- f
/ Design Constructed Notes
(fill out if
- different)
Pipe Diameter TMP: / 1.5" Stick Up(TMP) 30"
—
PMP: 1" Stick Up(PMP) ` 24",,,,/)
Borehole Diameter: 6"
Ground Surface 0.0' I _
HT Grout-- /Angle from Horizontal 90°
Casing Material
Carbon Steel
Other: — - Top of#00 Sand 1'
TMP Pipe Length 69.5' _-- Top of PMP Screen 3'
PMP Riser Lengt 5' __
PMP Screen Leng; 2' - Bags of#00 Sand 2.5
Bottom of PMP Screen 5'
Screen Material —
Stainless Steel Bottom of#00 Sand 7'
Other:
Bags of Cement 18
Slot Size 10 Bags of Silica 5.75
Installation Method Borehole Diameter 6"
DiPush
(Son)c, Bottom of TMP Well 67'
Hollow Stem Auger
Mud Rotary
Other:
Bottom of Borehole 67'ji
Post-Installation QC(to be performed 24hrs after installation) PM Log:Make/Model:
1)Confirm well is free of grout I Depth to bottom of TMP[ft bTOC]: Design Constructed Time: ��; F, Reading: i ['� PPM
69 5' Time: r h. ,c Reading: 6 ., D., PPM
Depth to bottom of PMP[ft bTOC]: 7' Time: Reading: PPM
if greater than or equal to 1ft 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 bgs Notes:
Depth to Grout, Depth to Grout,
Date TMP[ft bgs) PMP[ft bgs)