GW1--07058_Well Construction - GW1_20231102

WELL CONSTRUCTION RECORD GW-1
f For Internal Use Only:
1.Well Contractor Information:
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Well Contractor Name 14.WATER ZONES
f�
7 r FROM TO DESCRIPTION
3$ / U /q ft. ft.
NC Well Contractor Certification Number ft. ft.
IS.OUTER CASING(tor multi-eased wells)OR LINER(if a livable)
e•arC a,4 e ,)r/ l///\ice FROM I TO 1 DIAMETER THICKNESS MATERIAL
Company Name D. ft. In
2.Well Consh uction Permit#: A [\L'!?C 1 /l� ` 16.INNER CASING OR TUBING(geothermal closed-loop)
f �7.•ae FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pe nits(i.e.U/C County,State,Variance,etc.) ft.
R. in.
3.Well Use(check well use): Perfr.,/, wig W e_;le e 4e
ft. ft. In.
Water Supply Well: 17.SCREEN
DAgricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public ft. R. in.
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single)
❑Industrial/Commercial ft. rt. In. —
❑Residential Water Supply(shared)
❑hrigation 1&GROUT
❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
OMonitoring ❑Recovery
Injection Well: •
/� ft.
rt.
Recharge (roundwater Remediation R' R. --
❑Aquifer Storage and Recovery OSalinity Barrier 19.SAND/GRAVEL PACK(D'applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage • ft. ft.
❑Experimental Technology ❑Subsidence Control
ft. ft.
❑Geothermal(Closed Loop) °T�racer 20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Heating/Cooling Return) �othcr(explain under#21 Remarks) OM TO DESCRIPTION(color,hardness,soh/rock type,grain she,ets.j�
ft.
4.Date Well(s)Completed: 2-3 � int.
Z S ,Ft( rif joi y t el SCwv• eE a jd7
PWellID# I R. ft / nn I
• tIT I`a f $id tar 12 S�a/v fX
Sa,Well Location: {t, g
,4& ONe}1 our CkO. ,erY S,,,rru4 S ire Ne A a zi61,w9Y "• R.
Facility/Owner Name Facility lOtl(if applicable) ft. ft.
z1t71 ev�e i3lr,,7iY tcj ,,, filet 285 y‘ ft. ft. NOV J 2 20Z3
Physical Address,City,and Zip ft. ft, —
ON-S/0 LO 1/3%03a y7818 f/211j��.REMARKS ^
County Parcel Identification No.(PIN) / -t ,. C LL.✓ ...rN$'1--./144 j 7 a'
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Seep,tt./•il a l?scht�I\oft a Fer Co,sJro►R -;otve4 ettnl Is
(if well field,one Iat/long is sufficient)
{6f 22.Certification:
y� . /�7 L//I/o o N " 7�. .�66 at) W
��� j � / ��
6.Is(are)the well(s): fl rmanent or ❑Temporary Sssignaturc of c tficd Well Co MICRO' Date
By signing this form,I hereby cent/•that the twills)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or NI 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Olds is a repair,in out known well construction information and explain the nature of the ofthis record has been provided to the OW/owner.
repair-under#2/remark section or on the back 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S 7 (ft.)
For multiple wells list all depths if different(example-3@200'and 2@@I00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ip (ft.) 24a. For All Wells: Origiinal form to Division of Water Resources (DWR),
/('water 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(I(IC)
�J Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /1 O fa-SOW/C.
(i.e.auger,rotary,cable,direct push,etc.) 24e.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: i
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018

•
40* TEQRATHERM ISTD Heater Boring Construction Detail Revision#: 0
Release date: 5/12/23
Approved by: SL
Well ID H-31 !
Date
49 9-- "G 3 V(4-
Oversight 0� . Job It R23-104
Driller
•• cted
(fill out
plesigd differe ) Notes
--Stick Up Height
1/2"Thermocouple pipe?
24"
Thermocouple Length 58.67' -
Ground Surface 0.0' •
Heater Can Conductive HT Grout— Angle from Horizontal 90°
s.
C___Sched&e-40—"`"" .::,;...,,
Borehole Diameter 6"
Heater Can Length 59 ft
S Gal Buckets of Graphite 3
Bags of Silica 4
Heater Can Diameter 3 (
Bags of Cement 13
Installation Method
Dirsq Push
o.Di4a.-'
Hollow Stem Auger
Mud Rotary
Other:
Bottom of Heater Can 57'
Bottom of Borehole 57'
Post-Installation QC(to be performed 24hrs after installation) PID Log:Make/Model:
1)Confirm well is free of grout Design Constructed Time:
�• Q Reading: n., r., PPM
Depth to bottom of well(ft bTOC, co' Time: 47:Ej Reading: Q t, PPM AR.
if greater than or equal to lit less than designed alert the office Time: i `--) ' Reading: h . PPM
2)Confirm grout plug reaches ground surface Time: Reading: PPM r
repeat daily until depth to grout is Oft. Time: Reading: PPM
Date Depth to Grout[ft bgsj Notes: