GW1-2022-01604_Well Construction - GW1_20220201

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
`l;,NVe11 Contractor Information:
Kyle C. Shaw 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name *�4 R
4521-A
NC Well Contractor Certification Number 15.OUTER CASING for multi wells OR LIi�fER f a licable
Advanced Well Drilling, LLC FROM TO DIAMETER THICIxTIFSS MATERIAL
rc ft. 6 In.
Heavy PVC
Company Name
��, f 16.Il�AtER CASING OR TUBING eother mal cl ICKN
2.Well Construction Permit# FRont To DIADD?TER THICKNESS DtATERI U.
List all applicable well construction permits("i.e.UIC.Count:State, Variance,etc.) ft. ft.
3.Well Use(check well use): rc % in
Water Supply«'ell: 17.SCREEN
upP3 FROM TO DIAMETER' I SLOT SIZE I THICKNESS I MATERLa1,
LlndustriaWommercial
ral ❑\4unicipal/Public n ft. is
al(HeafingtCooling Supply) ®Residential Water Supply(single) ft in.
❑Residential Water Supply(shared) is.GROUT
❑Wells>100,000 GPD FROM To .rATERIAL Ea>pLacEnmvr METHon s At�totl`T
on- aer Supply Well: RJ6 "- Bentonite Poured
01%2onitoring ❑Recovery ft. iL
Injection Well: ft. ft.
❑Aquifer Recharge ❑Ground«ater Remediation
19.S4ND/GRAVEL PACK irapplicable)
❑Aquifer Storage and Recovery El Salinity Barrier FROM TO I MATERIAL EMPL4CEMFIYT METHOD
❑Aquifer Test ❑Stormaater Drainage ft. n
❑Experimental Technology ❑Subsidence Control R it
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLL>\GLOG attach additional sheets if necessary
❑Geothermal(Heating/Cooling Return) ❑Other(e: lain under#21 Remarks) FROM To DESCRIPTION(color,hardness,svlltroci e,Amin dm,etc.)
fL
%-I e�
4.Date Well(s)Completed:��-=�`- Well ID# ft. �� ft
5a.Well Location: 1 rr 1zw
" 5 _• .
Facility/Oi%merName Facility IDm(ifapplicable) fI ft r ( ii s�
i2a.(-X� J604 oF, ago n. IL
Physical Address,City,and Zip
REMAt.
RKS '
County Parcel Identification No.(PIN)
(f'
5b.Latitude and longitude hi degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3 - 1yS N �S�.rzolgq W
6.Is(are)the well(s): InPermtnent or ❑Temporary Srsnat of Certified Well Contractor Date
Bvsigning thisform,I hereby certify that the well(s)war(were)constructed in accordance with
7.Is this a repair to an eidsting well: ❑Yes or 81NTo 15.4 NCAC 02C.0100 or 1 SA A'CAC 02C.0200 11 ell Construction Standards and that a copy
If olds is a repair,fill out known well construction hfi orniation and explain t)te nature of the of this record has been provided to the well owner.
repair under 421 remarks section or on the back of this form
23.Site diagram or additional well details:
8.For Geoptobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional sell construction info
constmction,only 1 GVl'--1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: e 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ��J (ft) Submit this GW-1 within 30 daysI of well completion per the following:
For multiple wells list all depths if different(example-3 200'and 2ia'r 100')
10.Static water level below top of casings (ft) 24a. For All Wells: Original foim to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is abo%v casing,use
11.Borehole diameter (in)6 24b.For Infection«'ells: Copy to DWR,Underground Injection Control(IUC)
nt Pro_eratn,1636 MSC,Raleigh NC 27699-1636
12.Nell construction method:Air-lCa�e.ir�w_ '
24c.For«ater Supply and Open-Loop Geothermal Return\i%ells:Copy to time
(Le,auger,rotary,cable,direct push,etc.) county environmental health department of the county uvhere installed
FOR WATER StTPL1'WELLS ONLY: 24d.For Water Wells produ ' over 100 000 GPD:Copy to DWR,CCPCUA
Air Permit roam,1611 MSC, el NC27 W.I 11
13a.Yield(gpm) 5 Method of test:
13b.Disinfection type: HTH 4amunt:
Form G6V-I North Carolina Department of Errvironmental Quality-Division of Water Resources Revised 6-6-201 S

• Lkja
GASTON COUNTY DEPARTMENT OF HEALTH&HUMAN SERVICES
ENVIRONMENTAL HEALTH DIVISION
991 W.HUDSON BLVD.,GASTONIA,N.C. 28052
704-853-5200
i 4 t
Permit Void After-60 Months WELL INSTALLATION OR REPAIR PERMIT �t
PERMIT# 13519
Owner/Applicant: �� ` 'Date-
Mailing Addres t
Lot A Subdivision/Park c Lot# Block#
PROPERTY LOCATION �..
Signature of applicant or authorized agent
Type Size Depth Casing Depth
Casing Type Static Level Yield Grout
Grout Date Contractor/Driller
S
Distances Must Conform ITE SKETCH—No Scale
To LocaUState Codes.
Most Common Examples Are:
1. Water Tight Sewer Line...... 50'
2. Ground Absorption
Sewage System................100'
3. Building Foundations.......... '
PID#
PIN#'3 0% 1/
GRID# '4 (/ Z-4A 4 /
This permit do snot
the well/septic contractor
from complying with all
Gaston County and/or North 5
Carolina Laws,Rules,
Regulations and Ordinances. sot
2Zq
t�i�Gt- #-S+- �
WATER SUPPLY INFORMATION:
• Well location,installation and protection must meet state and local regulations,and must be inspected and approved by a representative of
the Gaston County Health Department before any portion of the installation is put into use.
• The siting of the well by the Health Department staff'is to provide protection from KNOWN possible sources of contamination. No quantity
and/or quality of water is guaranteed at any site by the Health Department
• After the well is in service,contact the Gaston C
samples. ounty vir nme tal Health Sec 'on(704-853-5200)for bacteriological and inorganic water
-
DATE ISSUED EHS
DATE WELL HEAD INSPECTION COMPLETE
FEE PAID S DATE IP#
RECEIPT#
'DATE SAMPEkS COLLECTED DA BACTERIOLOGICAL RESULTS ` RES TS
Original White: Health Department. Pink: Inspection Dept. Yellow: Applicant Copy