GW1-2021-07295_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Kyle C. Shaw 14.NVATER ZONES
Well Contractor Name FROM TO 'DESCRIPTION
4521-A io '� 10 ,
�l s
olqn
NC Well Contractor Certification Number 15.OUTER CASING forulti-ca hells)OR•LI�'ER if a lipble
Advanced Well Drilling, LLC FRR�OA m
1 TO MAMTER THICh�IESS 1L4TERLIL
Company Name v fL 'L 6 in.` Heavy I PVC
/�/ f 16.INNER CASING OR TUBING eothurnatclosed-loon)
2.«ell Construction Permit rl 1 t"U L a FROM TO DL X ETER I THICENM MATERIAL
List all applicable nmll construction ernrits i.e. IC. ountt:State, variance,etc.) R. ft.
rrL
PP p(� G T_
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO I DL0MTER I SLOTSIZE I THICKNU-ss 1LATERIAL
❑Agricultural ❑Municipal/Public fL f(- in.
❑Geothermal(Heating(Cooling Supply) ®Residenfial Water SupphP(single) fL iL in.
❑Residential Water Supply(shared) 18.GROUT
01ni ation ❑Dltells>100.000 GPD FROM To ilUTERMI E\IPLACElIE\T MEMO &AMOUNT
Neon-Water Supply Well: ft () ft Bentorlite Poured
❑Monitoring ❑Recovery ft ft.
Injection R'ell:
❑Aquifer Recharge ❑Groundwater Remediation ft. fL
❑Aquifer Storage and Recovery ❑Salinih 19.SAND/GRAVELPACK f applicable)
Barrier FROM TO I MATERIAL I E111PJ kCEl1ENT METHOD
❑Aquifer Test ❑Stonnwater Drainaze ft. ft.
❑Experimental Technology ❑Subsidence Control it fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(HeatingiCooling Return) ❑Other(explain under Y21 Remarks) I
FROM TO DESCRIPTION(color.hardness soillrocktype,Mtn stm,etc.)
(C 0 Aul
4.Date Well(s)Completed: 2`'r-)-X l Rtell IDS p fL fL tit
rya.N1"ell Location: It
lz9 u ft.
ft. 4 ft.
Facility/Owner Name ` - Facility ID=(if applicable) f.L fL r P
e__ tit 1r
Physical Address,City,and Zip ft.
�Y1C 211(1_ 21.REA4ARKS C- 5
County Parcel Identification No.(PIN) v Grt '"..
nr ��
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient) 22.Certification:
6.Is(ane)the well(s): [I Permanent or OTemporary SignatmVe of Certified Well Contractor Date
By signing this form 1 hereby certifi,that the well(k)was(were)constructed in accordance uIth
7.Is this a repair to an existing well: ❑Yes or 8No 15.4 NCgC 02C.0100 or 1 SA ACAC 02C.0200 Kell Construction Standards and that a copy
If this is a repair,fill out Brown well construction h for»tation and explain the nature of the of this record has been provided to the well oxmer
repair tinder=21 remarks section or on the back ofthis form
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal%4ells having the same You may use the back of this page to provide additional wail construction Info
construction.only 1 Gl[%-1 is needed. Indicate TOMAL\tL'A4BER of t,,zlis drilled: (add'Sze Over'in Remarks Box).Youmay also attach additional pages if necessary.
24.SUBrINIITTAL IINSTRUCTIOI\S
9.Total well depth below land surface:_ �� (ft.)
For multiple wells list all depths if different(example-3 a1700'and2@700') Submit this GW4 within 30 days of well completion per the following:
10.Static water level below top of casing: 10ft 24a. For All Wells: Original font to Division of Water Resources (DWR),
If Water level is above casing.use"=" ( ) Inforrnation Processing Unit,1617\4SC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (m) 24b.For Injection Wells: Copy to DW-F Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,INC 2 7699-1 63 6
12.Nell construction method: A 1 r--k±>s;
(ie.auger,rot 24c.For\Voter Supply'and Open-Loop Geothermal Return Wells:Copy to the
ary,cable,direct push,etc.) county environmental health department of the county where installed
FOR t"ATER SUPPLY WELLS ONLY: 24d.For IVater Wells ProducinE over 100 000 GPD:Copy to DWR CCPCUA
13a,field(gpm) � _ Method of test: Air Permit Program,1611 r 4SC, eigh„1\C 27699-1611
11; HTH -
13b.Disinfection type: Amount:1/6s
North Carolina Department of Environmental Quality-Division of Water Resources Revised_ 8__0t c

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