GW1-2022-01607_Well Construction - GW1_20220201

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.-Vell Contractor Information:
Kyle C. Shaw 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name
4521-A ?S" �Z�7� r'1
ft. %
NC Well Contractor Certification Number 15.,OUTER CASING for.. ultl-cased.ivells OR LIAiER rf n liable
Advanced Well Drilling, LLC FRO.r TO DIAMETER rtarcr�vcss DL4TERL•11,
tti 6 in• Heavy PVC
Company NameIIVl�'ER G OR TUBING eothermel closed-moo
2.Well Construction Permit#: FROXI To DIAMETER MCK-NTSS MATERIAL
List all applicable uef/construction permits(i.e.WC,County;State,Variance,eta) IL IL in.
3.Well Use(check well use): fL n. to
17.SCREEN
Water Supply Well: FROM TO MAMETER SLOT SIZE THICIGSIM MATERIAL
❑Agricultural ❑A4unicipal/Public frt, fL in
OGeothemial(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100.000GPD FROM TO MATERIAL EMPLACEMEM1?NETHODB:>v\TOUT
Pion-Water Supply Well: IL � a Bentonite Poured
❑'Monitoring ❑Recovery fl tL
Injection Well: tL
❑Aquifer Recharge ❑Grounduater Remediation
19.SAND/GRAVELPACK rfm livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM . TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormaater Drainage fa. fL
❑Experimental Technology ❑Subsidence Control f. IL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessat v
FROM TO DESCRIPTION(color, rdness.soutrwk tv size,etc
❑Geothermal(HeatinglCoolins Return) OOdrer(explain under 921 Remarks) ft ,/ � 1✓r��
4.Date Well(s)Completed: f Well ID# 0 ft
5a.Well Location:
fL
{-10
Facility/Ovvner Name Facility IDr(if applicable) tt ft.
r
t '7�r3 % %
ft. ft.Physical Address,City,and Zip
.�
21.RE2►MARKS
County Parcel IdentscatiORNo.(PINT)
5b.Latitude and longitude in degrees/nunutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
Af
6.Is(are)the well(s): GPerminent or ❑Temporary Srgnat of certified Well Contractor Date
13v signing this form,I hereby certify that the well(s)rear(were)constricted in accordance wdth
7.Is this a repair to an existing well: ❑Yes or NNo 1 SR NC.4C 02C.0100 or 15.4 AtCAC 02C.0200 lirell Construction Standards and that a copy
if this is a repair,fill out knou n well constriction it fornmtion and explain the nature of the of thus record has been provided to the well owner.
repair under."21 rentarla section or on the back of this fora
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havirmg the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL N AMBER of hells (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: �✓� (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dif ferent(example-3 a 700'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (D)iR).
10.Static water level below top of casing: e 0 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing rue"="
11.Borehole diameter: 6 (m) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A.r- Pe,4•v^t`4
24c.For Rater Supply and Openi Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push•etc.) I county environmental health department of the county wiere installed
FOR WATER SUPPLY«'ELLS ONLY: 24d.For Water Wells producingover 100,000_GPD:Copy to DWR,CCPCUA
l
Air Permit Program,1611 RISC lei_ ,NC 27699-1611
13a.Yield Wm) -Method of test:
13b.Disinfection type: HTH Arnount:
Form GW-1 \orth Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-201 S

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