GW1-2021-06931_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD(GW-1) For intemal use Only: E
1.Well Contractor Information:
Kyle C. Shaw fl, 14.WATERZONES
Well Contractor Flame `3 ' FROM TO DESCWTION
4521-A )' o n l m
ppAYxj2021 n fL
Well Contractor Certification Numbei l��y
r+rn{ec"' '. 1_)i�1115.OUTERCASING for multi nsedvicells ORLLYER tfa livable
Advanced Well Drilling LLC FRO•I TO DlattiEtER^ THICKNESS \LaTERIAL
r.r,-a".:11 i"^ I-1A It. in, y
6 Heav PVC
Company Name .v
E���- Z �6(ti �� 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: U FROM TO DIAMETER'in.
THICKNESS AUTERUL
List all applicable well construction permits(i.e-L7C,County,State,Irariance,etc) H
3.Well Use(check well use): fL fL in.
17.SCREEN
Water Supply Well: FRO\I I TO DWNIErEit SLOT SIZE I THIC104ESS hL4TERIAL
❑Agricultural ❑\4unicipal/Public tL fL la .i
❑Geothermal(Heating/Cooling Supply) C1Residential Water Supply(single) fL fL in.
❑lndustrial/Commercial ❑Residential rater Supply(shared) 18.GROUT
01nigation 01ATells>100.000GPD FROM TO MATERLIL EMPLACEAELNTMETHOD&AMOUitT
Non-Water Supply Well: 0 ft. 6 fL Bentonite Poured
❑Monitoring ❑Recovery fL ft
Injection Well: f. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAiVD/GRAVELPACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EI LI&CEN1 OD
❑Aquifer Test ❑Storm-ater Drainage % n
❑Experimental Technology ❑Subsidence Control R v-
❑Geotheinial(Closed Loop) ❑Tracer 20.DRII LING LOG taWich additional sheets if necessary
lU
FROM TO DESCRIPTION(color,hardness soraek ix e.Yalu size,eta)
[]Geothermal(Heatiog/Cooling Return) ❑Outer(explain under=21 Remarks) tt. r'`it2
4.Date Well(s)Completed:3"� ? \yell IDr? (} ft. [ fr Hai. 41
Sa.Nell Location:
e. rL
Facility/O erName FacilimID-(ifapplicable) fL ft
Si.
Physical Address,City,and Zip ft fL
21.RENJARKS
L;i�t rai r�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s): CPermrnent or ❑Temporary KpnatA of Ccrti ied Well Contractor Date
Brsigning this forms,I hereby certii ,that the trell(s) ,vs(here)constnicted in accordance uith
7.Is this a repair to an existing well: QYes or MNo 15A,\'G4C 02C.0100 or 15A ACAC 02C.0200►Fell Constnicbon Standards and dint a coln=
If this is a repair,fill out kmoan well constniction information and explain the nature of the of this record has been protdded to the cell owner.
repair under 421 remarks section or on the back of this fornc 23.Site diagram or additional well details
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having die same You may use the back of this page to provide additional well construction info
construction,only 1 GW-i is needed. Indicate TOTAL NUMBER of nails (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: r� 24.SUBI\RTTAL INSTRUCTIONS'
9.Total well depth below land surface: Submit this GNV-1 within 30 days of well completion per the following:
For multiple wells list all depths if d{Qerent(example-3(arff 00'and?@!00')
10.Static water level below top of casing: i� (ft) 24a. For All Wells: Original form f to Division of Water Resources (DWR),
tf wirer level is water
le el be use o " Information Processing unit 1617 MSC;Raleigh,SIC 27699-1617
11.Borehole diameter: 6 gym) 24h.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
,a 1 9r �t Program 1636 MSC,Raleigh,INC 27699-1636
12.Well construction method: A!r s E, 24c.For Water SuvDIv and Oven-1,6oD Geothermal Return Wells:Copy to the
(ie auger,rotary,cable,direct push,etc.) f county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produchm over 100 000 GPD:Copy to DWR,CCPCUA
Air Permit Program 1611 a\4SC,Raleigh, tC 27699-1611
13a.Yield(gpm) 2-,1n Method of test: E
`/t HTH '
13b.Disinfection type: Amount: lhS
_1 North Carolina Department of Enivonmental Quality-Division of Water Resources Revised 6-6-201 S
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