GW1--07100_Well Construction - GW1_20231103

WELL CONSTRUCTION RECORD(GW-1)
For Internal Use Only:
7
I.Well Contractor Information: ' .
•
711 d-14' W a M,b4/- 1 . l
14.WATER ZONES ' I I
Well
Contractor I�atttc, FROM . TO •DESCRIPTION
3O7f!A ft. it.
v
NC Well Contractor Certification Number ft ft.
' J ' ' 15.OUTER CASING(for multi-eased wells)OR LINER if a !Roble
•
O.�oR+1•C c..y(e. b r.. f i/'v' FROM I TO. !DIAMETER •THICKNESS MATERIAL..
It. in.
•
Company Name 1 ft.j. (,
�i /� /� P 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: /A i.�I f C L 4 �3.•e . FROM . TO DIAMETER . THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.Coanzp,'State,Variance,etc.) • ft. ft:- in.
3.Well Use(check well use): ' r< ',d✓5 'Eo e- re 4e •
ft. ft: In.
Water Supply Well: 17:SCREEN '' ' •
❑Agricultltral FROM ' TO • : DIAMETER SLOT SiZE' THICKNESS .MATERIAL
❑Municipal/Puhlic • ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
tt:• ft. In:•
❑Indastrial/Commercial OResidential Water Supply(shared) -
❑hrigation IS.GROUT ..
❑Wel(s>100,000GPO FROM ' i TO ' 'i MATERIAL'' . I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. • ft.
❑Monitoring ❑Recovery . •
Injection Well: ft • fr.
❑Aquifer Recharge IBC,roundwater Remediation R. ft. i
e 19.SAND/GRAVEL PACK(if appllcabtc). .•
❑Aquifer Storage and Recov ry ❑Stilinity Barrier . FROM• TO MATERIAL EMPLACEMENT METHOD.
°Aquifer Test ❑Stonnwater Drainage • • ft. • ft. . I,
• ❑Experimental Technology ❑Subsidence Control •ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(E leating/L:ooling Return) tier(explain wider#21,Remarks) PROM TODESCRIPTION(color,hardness;soiUroek type,grain sizaete.l _
QQ 0 ft: 2 5 ft* Tom, �1_
4.Date Well(s)Com leted: ,�,p''� r'e /)g[P' _ A /
So.Well Location: • ft. ft.
1
A8, O,vc;Ji bur C16,verS Ss�rdt ;4,L ,1e /y'ci 0Z"I6Vgy9q rt.. ft, 1. i'.,-'_�,,, -
Facility/OscnerName Facility iD11(ifapplicable) ft•' ft. ' .-', r j ..`:*,-,,_
z 7 Ne r31(�tQy,��tr50N✓�•j/e} ".28 ft. ft. NOS J ,
Physical Address.City;and Zip ft. .. ft, lU -_. •", 2`123 „
O/U'SlO lJtl 21.REMARKS I 'a,'
�i31�13ay7g�8 _
County V n r .�:* `l
Parcel Identification No.(PIN) d 67 � .10%-et=Jry. r it it -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 5t!.CK aGh Ld4..1t'e�►a t for C���'SrrWC f i av eta i 11 S
(if well field,one Iaiilong is sufficient) 22.Certification:
3L>7L1/L/00 • N . '77. 36Gi4a w �� d
� i,- 3
6.Is(are)the well(s): t rmanent or ❑Temporary Signature of Certified Well Contnietor' • pate ' •
By signing this forth,I hereby cerdi/j that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No ISA NCAC 02C.0100 or i5A NCAC 02C.0200 Well ConStruction Siandra•ds and that a cola
([this is a repair.fill on:known s eil construction hilornration and explain the nature of the of this record has been.provided to the lu el!owner.
repair under 021 remarks section or on the hack bf this Cor•n,.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well constructioninfo
•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:
s�` 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: y T dr (ft.) •
i'
For multiple wells list all depths ildi/ferent(example-3Q200'and 22®100) Submit this GW-1 within 30 days of well completion per the following;
10.Static water level below top of casing: �Q :24a• For.All Wells: Original fermi to Division of Water•Resources (DWR),
if water level is shave casing,use^+' (ft•) information Proeessing Unit,1617IMSC;Raleigh,NC 27699-1617
I1.Borehole diameter: 6 in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
p Program,•1.636•MSC,Raleigh,NC 27699-1636
1212.Well construction method: tTl d t0. v✓If I L; ' I, : .
.Well o untie,'direct push,elm) -24c.For Water Stipply and Open=Lotip 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 iovl r 100,000 CPD:Copy to DWR,CC:PCl1A
I3o:Yield m Permit Program,'161.1 MSC,Raleigh,NC 27699-1 61 1
(gp ) Method of test: . .
•
•13b.Disinfection type: ' Amount:
l -
Form GW-I , North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6.6-2.01 S

VEW Boring Construction Detail Revision#: 1
lfi I TERRATHERM
a Release date:_6/27/23
rr..:.d.ccmnMY
Approved by: EH
Well ID V-3 Date —
Oversight b itt Orjf Job I R23-104
Driller • 0_,_ �l ftAra.�i-1� 41�,�/�
�( I I, Constructed
I (fill out if
Design different) Notes
I'
I 1l
„r,
—VEW Stick-Up Height 18" %
Ground Surface 0.0'
Conductive HT Grout— ; • ' �� P,r r I'
c
''& k, : 1} '-'Angle from Horizontal 22. a�.
y
a "t' „ `; Borehole Diameter 6" .
'4- 4 y Top of#00 Sand 13.5'
s t try . .
tial
)- , '� y Top of Screen 26.5'
4 • e~ i`w r'Ai` k 5 Gal Buckets of Graphite • 1 1' '
it a
�, -`. t.Bags of Silica 1..2 ',
(--\ Riser Length w : v 9
I \ Screen Length ft '.`r i'i I `
Screen Diamter 1 in i, " 0.'' Bags:of Cement /4 t'
4 9 p
&r.• n 5� k.' Bags of#00Sand 9.5 1 lk.
i
Installation Method i ." r` Gallons of Limestone 9.5 twrnF C, r•
tte
Direct Push
-o ow Stem Auger • M`s t �..
Mud Rotary ' , i d ,. I,
Other: � v � :
Icy&r ' 4,Bottom of Sand and Screen 41.5'
—, ,•,,'4 Bottom of Borehole. 41.5 , u I 11
1
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Post-Installation QC(to be performed 24hrs after installation) , PID Log:Make/Model. F.
1)Confirm well is free of grout Design Constructed Time: `�;470 ,Reading: 0 o 0 PPM
Depth to bottom of well[ft bTOC, -4a ft Time: .*/c3 .Reading: s 0 PPM
if greater than or equal to 1f t less than designed alert the office Time: q•f Reading: ,f, 6 PPM
2)Confirm grout plug reaches ground surface Time: Reading: PPM
repeat daily until depth to grout is Oft. Time: Reading: PPM
,
Date, : Depth to Grout[ft bgsj Notes: olyie (Ve-1/p
IIj