GW1-2021-06930_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use'Only: j
1.Well Contractor Information:
P
Kyle C. Shaw
C „„, 14.WATER ZONES l
FROM TO DESCRIPTION
Well Contractor Name ft
4521-A 1�."A'Y X 2021
n ft. ! r
NC Well Contractor Certification Number i �1 i sl I
r, 3;V 1 r: i G'SS I? 15.OUTER CASING for multi cased wells OR LL�TER if n lipble
Advanced Well Drilling, LLCin'��" y in s FROM TO DLtI4tEfER THICh1VESS 1LrTERLtL
�.de..t:ol� � G
Company Name ft ft 6 tn. Heavy PVC
16.INNER CASING OR TUBING eothen al closed-loop)
2.Well Construction Permit#: �-" Q FROM I TO I DIAhIEfER THICICPTss MATERIAL
List all applicable Hell eonstniction permits(i.e.1.7C Counr),State,Variance,etc i 1t• M in
3.Well Use(check well use): tt ft
in
17.SCREEN
Water Supply Well: FROM TO I DLALMUER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Pubiic ft fL in.
❑Geothemial(Heating/Cooling Supply) MResidential Water Supply(single) fL ft in.
❑IndustriallCommercial ❑Residential Water Supply(shared) 18.GROUP
Olrrigalion ❑Wells>100.000 GPD FROM TO MATERIAL F.MPLACEr*f&N'f METHOD&AMOUNT
Non-Water Supply Well: f- ft Bentonite Poured
❑Monitoring ❑Recovery fL it
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundvmter Remediation
19.S.A-NLD/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROI\I To I MATERIAL E11IPL9CEM&M'T METHOD
❑Aquifer Test ❑Stormv,,ater Drainage (L n
❑Experimental Technology ❑Subsidence Control it- n
❑Geothermal(Closed Loop) ❑Trace• 20.DRm1 r.ItvG LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness, illrack type,min size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. fL
�• Ch
4.Date Wells)Completed: '?5` Well ID# ft' E
Q41 it. fL IJ
5a.Well Location: rre
iC
-� fL R
Facility/Owner Name Facility ID=(if applicable) % ft
`` - s ft It.
Physical Address,City,and Zip
zL REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficiem) 22.Certification:
?S,4a2b"t N -'?I-i-7173 W
6.Is(are)the well(s): nPermanent or ❑Temporary Sumanafe of Certified Well Contractor Date
I3vsigning thisforni.I hereby certifi=that the well(s)was(were)constnicted in accordance ulth
7.Is this a repair to an existing well: ❑Yes or 8 No 1 SA A'CAC 02C.0100 or 1 SA A`CAC 02C:0200 IVell Constriction Standards and that a cony
Iftlds is a repair,fill ont known well constriction it formation and explain rile name of the ofthis record has been prrndded to the sell owner.
repair under 421 remarks section or on the back of this form 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 hell construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NU'\4BER of vmlls (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRucrio Tsi
9.Total well depth below land surface: d� (%) Submit this GW-1 within 30 dais of well completion per the following:
For multiple wells list all depths if different(example-3(atr00'and 2@100')
10.Static water level below top of casing: (ft*) 24a. For AD Wells: Original form to Division of Water Resources (D)AM),
If nttrer level is above casing use"+" Information Processing Unit.1617 MSC,Raleigh.NC 27699-1617
11.Borehole diameter: 6 (�) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(ILIC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Arr - 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) I county environmental health department of the county where Installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing oyer`100 000 GP
rtD: R,Copy to D% CCPCUA
13a.Yield Wml) ?Method of test:
Air Perm rogram 1611 MSC,Raletgh,INC 27699-1611
13b.Disinfection type: HTH Amount: ���
North Carolina Department of Enironmental Quality-Division of Water Resources Rem-s-

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