GW1-2021-02679_Well Construction - GW1_20210809

WALL CONSTRUCTION RECORD(GW-1} For Internal Use Only:
1.«'ell Contractor Information:Kyle C. Shaw -3 14.NyATERZONES
FROM TO DESCRIPTION
Well Contractor Name � �6 tt �ft -i 1
V d.
4521-A
NC Well Contractor Certification Dumber 15.OUTER CASING for multi-ca wells OR LIINER 1f a linable
Advanced Well Drilling, LLC� ,�� c35� FROM TO DIA?i ER TMCA.NM ALaTERL1L
.� re,<� � ft. ft. 6 in. Heavy PVC
Company Name f 1 4����JZ 76.IPIlY-ER CASING OR TUBING eothermnl closed loo
2.«'ell Construction Permit#: V 0 3%5 1 '�� F7tOaI r0 DIAMETER THICI.TFSS \LITERL4L
List all applicable.+ell construction permits(i.e.GIC Cal{'r,'�r le.1 riance,etc.)
fL fL in.
It. fr. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM i0 DLAMEFER 1L
0-Agricultural ❑Municipal/Public ft. tt in
❑Geothermal(Heating/Cooling Supply) 19Residential'Water Supply(single) r (L in
❑brdustrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
11fi-riization ❑Virells>100.000 GPD FROM TO MATERUL EMPL4CE\iENT METHOD&AMOLTT
Non-Water Supply WWI: - �/ fL " ft. Bentonite Poured
❑Monitorine ❑Recovery n• fL
Injection\hell: fL It.
❑Aquifer Recharge ❑Groundwater Remediation 19.S.4NDlGRAi'ELP�,CK(mfa liable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To NIATERIe1L E-NIPL4,CEMENT METHOD
❑Aquifer Test ❑Stormmmater Drainage fl ft
❑Experimental Technology ❑Subsidence Control ti iL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
FRO\I TO DESCRIPTION(color.hardness mltfrocR type,^rnln size,etc)
❑Geothermal(HeatingiCooling Return) ❑Other(explain under-,21 Remarks) ft
4.Date R'ell(s)Completed: J°1, Well ID9 { fL tt
fL r'F, iL
5a.Well Location: fL
"�1•!
R
Facility/Owner Nam Facility ID=(ifapplicable) ( / J G
11 t7 - aCo G)�
60!:41 Physical Address,Cit a ft-
dress, Zip � iL
21.REMARKS N.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlone is sufficient) 22.Certification:
6.Is(are)the well(s): PPermane _,or ❑Temporan S,ss,a ofCendedi�%ell Contractor Date
B,signing this forni,I hereby cent h,that the well(.)was(were)constructed in accordance oath
7.Is this a repair to an eiistitmg well ❑Yes or L No I5A NCAC 02C.0100 or 15A NCAC 02C.0200 flrell Constiction Standards and that a color
this is a repair,fill out known well constriction information curd explain the nahure orthe of tins record Iran been prmaded to the well rarer.
If
repair under h21 remarks section or on the back of this form 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 provide additional-well construction info
construction,only 1 GAI-1 is needed. Indicate TOTAL NUNIBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTION'S
9.Total well depth below land surface: 16 5 (ft-) Submit this G«14 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3t fo00'aid 2(o'd 00')
r� 24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing: CS f l (ft*) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If ureter level is abme casing,use"="
24b.For Injection Welts: Copy to DWR Underuound Injection Control(I1 iC)
11.Borehole diameter: 6 CHL) Program,1636 MSC,Raleigh,NC 27699-1636
12.NireR construction mmmethod: Ai(__/2,,40<7 4 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie auger,rotary,cable,direct push,etc.) county environmental health department of the county where mstalled
FOR WATER SUPPLY AITLLS Oi TLY: 24d.For NVater Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
Air Permit Program, 1611 MSC.Raleigh:NC 27699-1611
13a.Yield(gpm) f'^. Method of test:
HTH
13b.Disinfection type: Amount:
te*m Gw-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018