GW1--07096_Well Construction - GW1_20231103

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• BEI S�2UCTI0161 RECORDL_ 1�
For Internal Use Only: '
1.Well ContraetoI Jttfot'ntatiof: ' '
td t/1 t c-j' W t rt�l'ae 14.WATER 2ANEn I I r
Well Connector Name 1 .. FROM TO DESCRIPTION -- 1 _J
,g76 ft. ft
NC Well Contractor Certification Number ft I I
® bro.' 9 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
1 s0..�'C c'.ci e. 1 L'.ic 1.
4 FROM I TO DIAMETER• THICKNESS MATExiAL '-"
Company Name ft ft I I in. -
2.Wei!Construction Permit#:r erne �� 16.INNER CASINO OR TUBING(geothermal closed-loop) -
lt FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pe its(i.e.1.11C,County,State,Variance,etc.) ft. ft.-I in.
3.Well Use(check well use): erg iJ ,:io y ® %ir le
ft, ft. I in.
-Water Supply Well: 17.SCREEN --
IDA,gnicu}tttral FROM TO DIAMETER SLOT SIZE THICKNESS otA]ERIAL
OMunicipaUPublie • ft IL in.
OGeothermal(I eating/Cooling Supply) OResidentiaI Water Supply(single) __-
ft f4 in
❑lndustriaUCommercial OResidential Water Supply(shared)
Obligation • Is.GROUT - --
OWells>100,000 GPD FROM TO ' MATERIAL" EMPLACEMENT METHODS•AMOUNT
Non-Water Supply Well: - ft. ft.
OMonitoring IRecovery •' •. ' ft. ft.
Injection Well: ,
•
ClAquifer Recharge futldwater Retnediation it. ft.
1�;ro .
DAquifer Storage and Recovery [Salinity Barrier 19'SANiD/GRAM PACK(if applicable) •
,FROM TO MAT'E'RIAL EMPLACEMENT METH&
OAquifer Test OStormwater Drainage •. IL • ft:
❑Experimental Technology OSubsidence Control • . ft. ft. . . •
OGeothermal(Closed Loop) OT�racer '• - • 20.DRILLING LOG(attach additional sheets if necessary)
' OGeothermal(Heating/Cooling Return) er(explain under#21 Remarks) Flu* To OFm^CRIPTION'(color,hardness,soil/reek type, amsrae,ei ))_:
Ss
/� j ft- 2.S r° r� ' 1,l e �.
4.Date Well(s)Completed: P- '��a Well ID# f '' . ft. ft
5a.Well Location: ft. ft.
/Ir . Oiteenenar Ck&ver -� t :.
Facility/Owner Name FaaciltyID"(if applicable) fit. it. AIn n `---
2127 Z S'euN-e £/i/4 y t'�.50,4 t/r`i e) 2 S'. �ti ft. ft: '+iJ 9i" e L V 23 --
Physical Addrrs,City,and Zip ft. ft. Iri i r7r 2LV:::n Pr.-. U
ON10 t� • �3�d'i3J y��1� a1.REMARKS �';:'�,. ;n r.Li
County Parcel Identification No.(PIN) / C4/ "/ 4J a-e„.., x/r^ cj?d oit'' (du(//
3b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' ' Set°e, edeSche_vies.it-is L fo r C odv,s-trot e f;O a,.dd e t i I.S
(if well field,one tat/long,is sufficient) 22.Certifies on' i
:III a7I/Lf N -77; 3d1 ii to
_...._.) /41-2-6"--zz
----,--1-#.-1-:.."A-"."---....,...../1-/6* ' - ---' -
6„Is(are)the svell(s): 1$ ermanent or OTemporary Signature of Certified Well Contractor! , Date
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Bysigning thisfornr,l hereby cer/ifj•that the tvell(s)was(were)constructed in accordance with
7.is this a repair to an existing well: Dyes 'or Mtn'''.
ISA NCAC 02C.0100 or JSA 1VCAC t12C.0200 Well Construction Standards and that a cope
If this is a wait-fill out known well construction Information and explain the nature of the of this record has been provided to the lie owner.
repair under 021 remarks section or oh the back of this fora:.
23.Site diagram or additional well details: -
8.For Geoprebe/DPT or Closed-Loop Geothermal Wells having the same . You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells • •(add'See Over'in Remarks Box).You may also attach additional pages if net:assar i.
drilled: I
24.SUBMTTTAL INSTRUCTIONS •
P.Total well depth below land surface: 83 .(ft:) • .
For multiple wells list all depths ifdeerent(example-3Q200'annd 2QI00) Submit this GVY 1 within 30 days of►ell completion per the following:
10.Static water level below top of easing; !
, '24a. For All Wells: Original form! ,to Division of Water Rmourcm (l)lr R),
(ft,',Information Processing If water level is above casing,use-+'• '!l • :, g Unit,1617 MSC,Raleigh,NC 27699-!6I7
I!.Borehole diameter: (in.) .24b.For Iniection Wells:Copy t I pwR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method; RO,g t --.5-Ottle '
(i.e.augur,rotary cable,direct push etc.) 24e.For Water Supply and Open-!loop Geothermal Return`!Neils;Copy rp the
_ county environmental health department of the county where installed
i OR `t ER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPC:UA
13a.Field(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gp I 1
I
l:lc.Disinfection type:-„_ Amount: • -
Form CW-f . North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-5_01 e

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M4-1.4:6-Ptasa.Eatract=Wag ReyfAcsr4.-..: -1-7 . _
TERRATI-FT-IM
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• Oversight I t., SzbiIg;; •'III7'.'1-k*" 5:.*Mr7ggilkftMiVI-4A*
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Driller Gt Fros.n ii 11/%2.A)`A.13 6'7/7 ; • ,,,,,,:„,,,•:•,.,4,,,1*-••,•tr,,iN,.... --,:-:,...„:„,
- 4-1-',... ..-•,...;.-e,,,:k,,,,,,,,,-.x.-4,0-f,ww•,n
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i • pi cute :. .. .. '.':-.:...,:f.M.4-.''_:V
,. . Well Diameter 4" .
torment)
Borehole Diameter . 8".
—Stick Up Height ide (c,0
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± Ground Surface 0.0' .
•
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Angle from Horizontal 38°
. ' s.I647,,If g4I1`4613 I
I . MO o..:,o,:k, •
ilyz4t,,_Top of#00 Sand . 14'
-Ril';,f0 0•0:i;,
Casing Material "- --
Ftgiq 4144^ :' '
•-•f,-..,..*- - - !,;,k-7=f
Carbon Steel
• 4r'4',•-._.Iggi-; Top of Screen 16'
Other ig4011, . PPAg ,
ig?':,.,k,,,p•-.....,i4,,Arri
470lizir',3 ,,,,f4p.,-- _ • •
Riser Length 20 ft 0.,$ eAg. •• ;,.azfl;•-- •:':.T.s.4‘;'":
Screen Length 65 ft -1:;.-,ie.r•A • N'A"-AIit Bags of#00 Sand .413* 3s.. _. ..., ,
. ,,4,_, 5. (.67
•r!-,'1.=.4
Bags of Cement 6
'-',5'nfQ• •."'•$'%
::liti Bags of Silica • 2 Q
• „,„.„.„,„
. —_. ,1,1,11 J:
Screen Material zr',.0.5 .kiVr!.4 ,
.....0.2.. ---y .
Stainless Steel OM',1, KAI Borehole Diameter 8"
ITh Fiberglass! _._. X p31
:•,•-ktrr
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. '•,d,-,iiz-g, PVC ....:i.',7 ,,”:,....4.:ra ,
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'1,,.‘'.'• Other ;04,.i i -'wio•
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Slot Size 10 .::-•:liliki - i Bottom of Sand 81'
( '• ' 1 i, • . ••,'.•:.1,,v.•-,•-• •:',•••e;;T.,
' ' • 'I.:J.•••••..Ii::::_, '".4±A'a• ,
: • :iT,'S;I4,i1II -10 Bottom of Screen 81.'
...i.,. -----4'41
Installation Method --. . ; 1 . •
HTGrout-,,,,,,,,,' ;:,"144:,.: • - :
,,
Hollow Stem Auger ,. . 1,7,.)- ','
...,l-,. Sump Length 2'
Mud RotarY •
,tilc
Other: ' ! ., .. !•:=N,,
1„,,f,,' Bottom of Sump 83I
: : •.
il •,,,,
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,11::;,",!,Bottom of Borehole 13)• '
, .
Post-Installation QC(to be performed 24hrs after installation) PID Log:Make/Model:
1)Confirm well is free of grout Design Constructed Time: Reading: PPM
Depth to bottom of well[ft bloc]: ' R7' Time: Reading:' PPM
if greater than or equal to lit less than designed alert the office Time: Reading: I PPM
2)Confirm grout plug reachesiground surface •• Time: Reading: I, PPM
repeat daily until depth to groUt is Oft.bgs: , . Time: Reading: 1 PPM
Date Depth to Grout[ft'bgs] Notes:
1 .
•
•
' 1
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: 1 .. , • , :, I 1
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