GW1-2022-01605_Well Construction - GW1_20220201

WELL CONSTRUCTION RECORD(GW 1) For Intemal Use Only:
1.Well Contractor Worrhation:
Kyle C. Shaw
14.WATER ZONES.
Welt Contractor Name FROM TO DESCRIPTION
4521-A Soa ft S0SfL
NC Well Contractor Certification Number
Advanced Well Drilling, LLC F1�5 OUTER CASING for llsmD�dRe OR�Ufa ll IA1ERUL
Company Name 0 ft 1, fL 6 in., Heavy PVC
16.INNER CASING OR TUBIISG(geothermal closed-loonl
2.Well Construction Permit#: I,�(� FROM TO DIAMETER I TAtct;VM I uaTEwA[
Gist all applicable well contraction permits(i.a It7C.Counn;State.Variance,etc.) fL fL in.
3.11'ell Use(check well use): ft. fL in.
Hater Supply Well: 17.SCREEN
FRO\f TO DW1tEIER I SLOTSIZE THICIu'�iESS 11rATERIAL
❑Agricultural ❑Municipal/Public rL fL in
❑Geothermal(Heating/Coofing Supply) MResidential Water Supply(single) rL, fL in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) lg,GROUT .
0irrigatton ❑Wells>100,000 GPD FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
)\Ion-Water Supply Well: IL rL Bentonite Poured
❑Monitoring ❑Recover= ft, ft.
Injection Nell:
er Recharge ft❑Aquif ❑ � eremeaon❑Aquifer Storage and Recovery ❑ h5alini Barrier 19.SAND/GRAVEL PACK(if a livable
FROM TO 1LATERIAL' EMPIACEAi&Y'T METHOD
❑Aquifer Test ❑Stormaater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control fL tL
❑Geothe[mal(Closed LOOP) ❑Tracer 20.DRILLLNGLOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soWrocktype, sue,etc
// ft ft.
4.Date Nell(s)Completed: 1Ve11 ID# ft 11L
Sa.Well Location: 4S fL ft.
(OalCI)aweA. ftSoil; ft.
Faccili�ty/-^O��tener//Name t ,, t'Facilitty�/ME(if applicable) f. ft.
j JOSDI. L?rrr._14 lit' 444uh ►VC. of iYJo2� tL fL --
Physical Address,City,ank Zip T tr fL
REMARKS
County Parcel Identification No.(PINT) ZI"29
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) /u' 22.Certification:
l>' • �
6.Is(are)the well(s): IlPernianent or ❑Temporary an&of Certified Well Contractor Date
Bvsigning thisfornt,I hereby ceni6•that the welts)was('were)constructed in accordance Iwth
7.Is this a repair to an existing well: 0-Yes or 81NTo 15A MC4C 02C.0100 or 15A MCAC 02C.0200 lVell Constnuction Standards and that a copy
If this is a repair,_fill out known well constriction information and explain the naarre of the of this record has been provided to the well owner.
repair finder 921 rentarka section or on the back of this fornc
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 iprovide additional hell construction info
construction.only 1 OW-1 is Headed. Indicate TOTAL NU,IIBER of%tzlls (add'See Over in Remarks Box).You may also attach additional pages if necessary
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:- S d.5 (ft.)
For nndtiple wells list all depths il'different(example-3Q200'mid 2�100') Submit this GNV 1 within 30 days of well completion per the following:
10.Static water level below top of casing: ft 24a. For All Wells: Original fort to Division of Water Resources (DVIR).
If water level is above casing,use••+• ( ) Information Processing unit,1617 MSC,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 (m) 24h For Injection Wells: Copy to DWR,Underground Injection Control(ItuC)
Program,1636 MSC,Raleigh.NC 27699-1636
12.NeIl construction method: 24c.For Water Supply and Open-Lo6ti Geothermal Return 1Vells:Co to the
(ie auger,rosary,cable,direct push etc.) county environmental health department of the county where installed �
FOR WATER SUPPLY WELLS OnZl': 24d.For Water Wells eroduciney over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
YY�� Air Pemilt Program, 1611 MSC,Raleigh,NC 27699-1 11
13b.Disinfection type: HTH Amount: 1I�5
C-V I North Carolina Department of Environmental Quality-Division of Water Resources
i Revised n3_01 t

_ ASTON COUNTY DEPARTMENT OF HEALTH&HUMAN SER
VICES
( ENVIRONMENTAL HEALTH DIVISION X
e
l 991 W.HUDSON BLVD.,GASTOIVIA,N.C. 28052 �".,o
704-853-5200 j
Permit Void After 50 Months WELL INSTALLATION OR REPAIR hEltlllllT !
PERMIT# 1 3635
Owner/Applicant: �� Date:
Mailing Address: Phone; - -�'�
Lot Area AM Subdivision/Park Lot# Block#
PROPERTY LOCATION 1
Signature of applicant or antho agent
TypeType S� Depth Casing Depth
Casing YF Static Level Yield Grout
Grout Date Contractor/Driller
Distances Must Conform SITE SKETCH—No Scale
To Local/State Codes.
Most Common Examples Are:
1. Water Tight Sewer Line„.... 5o, %4`�t�5}Q!� CaCcorcl,�n .�C O11 !1e
2. Ground Absorption
Sewage System...-...---- � � �1�5 1]
ii
3. Building Foandations.„.„_ 25' �I'1Cl q lc;t-t O>7-a.
PID# �j ��n--tacn Q minimum i a0'
25`
This permit does not relieveqin-I-a in a m;n,,munneve / i_ 1
the weWseptic contractor ! -�OaGk +r,, Q!t
from complying with all b
—
Gaston County and/or North l. 1 n�5� u C+U r,e-s
Carolina,Laws,Rules,
Regulations and Ordinances. PL
�-
S
5`?3 1037,
rQi0158.443 Lta��p r'sS715�4t�c
_ m ird
Welt Orem
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.
o After the well is in service,contact the Gaston County Environmental Health Section(704-853-5200)for bacteriological and inorganic water
samples. ..
DATE ISSUED 10 15 Z02—( 1k Egg /
DATE WELL HElTSPECTION COMPLE E HS
FEE PAID$ � DATE - RECEIP
DATE SAMPLES COLLECTED DATE OF BACTERIOLOGICAL RESULTS i RESULTS
Orlainal White: Health Department Pink: Inspection Dept YeIl 1: Applicant Copp