GW1--07032_Well Construction - GW1_20231102

WELL CONSTRUCTION RECORD(GW-1)
For Internal Use Only:
I.'Well Contractor Information:
WWI
s/' WI GC-IV W i Mber I
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3,876 A ft. IL
NC Well Contractor Certification Number ft. ft.
IS.OUTER CASING(for multi-cased wells OR LINER if a Iicahle -
�j ZL,-.�'C cs c. e. 4br /`2 n/L9 FROM I TO DIAMETER THICKNESS MATERIAL 1
Company Name if• ft. in•�
2.Well Construction Permit!l:�/�Q /� /� ` 16.INNER CASING OR TUBING(geothermal closed-loop)
r/A CLt t C L f l ,7.-',,L FROM TO DIAMETER THICKNESS :MATERIAL
List all applicable well construction pe stirs(i.e.li/C.County,State, Variance,etc) ft.
ft. In.
3.Well Use(check well use): Per."ilfi.✓� Wet- %leeee - 'ft. ft. in,
Water Supply Well: 17.SCREEN
❑Agrlcldtlrral FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) _
OlndustriaUComwercial rt. ft. In.
❑Residential Water Supply(shared)
18.GROUT
❑Irrigation -
❑Wells> 100,000 GPD FROM TO ' MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: /�� ft. ft.
❑Aquifer Recharge fli roundwater Remediation ft. ft.
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL
OAquifer Test EMPLACEMENT MET
HOD❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft,
❑Geothermal(Closed Loop) ❑Trace/ 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) Cher(explain under 021 Remarks) FROM TO DESCRIPTION(color,hardness,snit/rock type,grain sin.,�i;_).
o ft. Z S rr. A
4.Date Well(s)Completed: j q �/ Xi` �'��ei®�'"„g t'�`�Sltt'Av1 C�'G/eC
P /�^g��3 WelllDk f/ - �� 2Sn. -+- ft. f
5a.Well Location: fr. ft. --"
/)/3C_ o.ve)1 our Chewers ScpiTt•+•%!..Sie N•e b a 2.16 yyy95' ft. rt. -
Facility/Owner Name Facility ID/I(if applicable) ft. ft. - --
2/z'7 Zv re i3i1/dijTom.e1►.sflN✓� de, 28.s�5VZ It. ft.je NOV 1) 2 20?3
Physical Address,City,and Zip ft. ft. _
ON-5/0 W 2/3 7d l3a y7818 21.REMARKS County Parcel Identification No.(PIN) Ale cote"-0(.,.cam 64/;1-1,V�.` `t
� >rZ.;ir-,,e-fiaw Lac
..��rl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Seen,t'f eischerao-1 t - fo F'eO.'Srrri✓C f+o t+t.I a ICe i l s
(if well field,one(at/long is sufficient) 22.Certifications
3 L7y/yco N ' '7.7, 36II tea W
11/6 ,_7//„/„.,/,/e,6.Is(are)the well(s): l l rmanent or OTemporary /0._;r-2,3
Signature of Certified Well Contractor (�� Date
By signing this form,t hereby certi/j•that the twills)urns(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ttf1Vo JSA NCAC(/2C.0100 or ISA NCAC 02C'.0200 Well Construction Standards and that a cop.
!/this Is a repair,fill out known well eonstructinn information and explain the nature of the o/this record has been provided to the well otwter.
repair under/r21 remarks.section or on the hack of this forn,.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
S.For Ceoprobe/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: (ft.)
For multiple wells lies all depths if drflererr((example-3 ta100.and 2 4100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: /67 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11,Borehole diameter: 7 (in.) 24b. For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: NO tO..S ewi•e
(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,CCPCI)A
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6.20I8

ISTD Heater BoringConstruction Detail Revision a: o
TERRATHERM ;Release date_5/12/23_
•
Approved by SL__
Well ID H-45 Date 7.7' 2f
Nikk
Oversight Job# R23-104
Driller •Zd;,49ie-/-7
Constructed
(MI out if
Desi. different) Notes
a
1/2"Thermocouple pipe? -----Heater Stick-Up Height 30"
Thermocouple Length 37.67'
VEW Stick-Up Height 18" MI
Ground Surface 0.0'
Hearer Con Conductive HT Gmut—
Anpfe from Hosizo tt'+atl 90"
Schedule 80
Borehole Diameter 7"
Top of WO Sand 1'
Top of Screen 3'
Heater Can Length 38.5 tt 5 Gal Buckets of Graphite 0.5
Heater Can Diameter 3 in
Bags of Silica 0.75
Screen Length 10 ti.
Screen Dfamter 3 in Bags of Cement 2.25
Bottom of Screen 13'
Instakadon Method
Direct Push Bogs of NOB Sand 10.5
Sonic
Hollow Stern Auger Gallons of Limestone 10.5
Mud Rotary
Other:
Bottom of#00 Sand 30'
Bottom of Heater Can 36'
Bottom of Borehole 36'
Post-installation QC(to be performed 2Ahrs after Installation) PIO Log:Make/Model:
1 Confirm well is free of grout Design Constructed Time: I fyr (1�Q Reading: (l?o(") PPM
Depth to bottom of well lit blOC 3R 5' Time: ) ,, (?b Reading: Q e PPM
if greater than or equal to 1ft less than designed alert the office Time: L�;on Reading: r PPM
2)Confirm grout plug reaches ground surface Time: ,06 Reading: • PPM
repeat dolly until depth to grout is Oft. Time: 9,:Oa Reading: t( PPM
Date Dein))to Groin Ill bi;sl Notes:
Yell°(" ;//19