GW1-2022-08589_Well Construction - GW1_20220428

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1AN"ell Contractor Information:
• K-_C. Shaw, 14.WATER ZOA'ES
well Contractor Name FROM TO I DESCRIPTION
4521-A 305 ft- y05 rt I I n
ft. fL
NC Well Contractor Certification Number 1
15.OLTERCASING formulti�asedtirells OR LINER rra Ii6b►e
Advanced Well Drilling, LLC
FROAi TO DIAMETER I'HICIv'N'FSS MATERLAL
Company Name L 11 f ft :. 6 in. Heavy PVC
r4�' r! 16.INNER CASING OR TUBING eothermal closed-loan
2.Well Construction Permit#: /
/ �C 0.f FROM To DUMErFdt I Tmc!k,'�1ESs I n7ATEItIAL
List nil applicable Hull construction permits(i.e.WC.Counw,State.Irarionce,etc) ft ft in
3.Well Use(check well use): ft % in.
Water Supply Well: 17.FROM TO DLAAfETER SLOT SIZE I TJ9lC_M_9_V_-;_% 7 AfATERIAI
❑Agricultural ❑Municipal/Public rt ft ;in,
❑Geothermal(HeatinglCooling Supply) 19Residential Water Supply(single) rt ft. fn
❑Industrial/Commereial ❑Residential Water Supply(shared) —Ts—
.GROUT
❑lrri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD S,kMOUNT
Non-Water Supply Well: ft r y ft Bentonite Poured
❑Monitorilw ❑Recovery fL fL
Injection Well:
❑Aquifer Recharge ❑Groundtuater Remediation ft. Ft.
19.S.AND/GRAVEL PACK(it a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonn nater Drainage ft. it
❑Experimental Technology ❑Subsidence Control M fr-
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necesso
❑Geothermal(HeatingiCooling Return) ❑Other(explain under#21 Remarks) 1
FROM TO DESCRIPTION(color,hardness,mWrock type,grain size.etc)
4.Date Well(s)Completed: J '.)t \s'e11IDft IL J
Sa.Well Location: r ft ft
Facility/Owner Name /Facility ID>(if applicable) ft ft V f
(17 f �JP j f'P e ► Cr,l C —` E• �1 ft to
Physical Address,City,and Zip M
6�40r\ 21.REMARKS
County Parcel Identification No.(PIN) AP
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: A
(if well field,one lat/long is sufficient) 22.Certification
6.Is(are)the well(s): nTermanent or ❑Temporary Signatitde of Certified Well Contractor Date
Bvsigning thisfornt I hereby certify that the well(s)was(were)constricted in accordance mth
7.Is this a repair to an existing well: ❑Yes or 8No 15A XCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a cop,
If dris is a repair,fill out/ruox,»well construction ittforniation and explain the nature o(the of this is record has been proidded to the Hug owner.
repair under 421 remarks section or on the back ofthis farm
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the saute You may use the back of this page to provide additional tell construction info
.` construction,only 1 GW 1 is needed. Indicate TOTAL)\UNIBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessan'.
drilled: �y 24.SUBIIITTAL INSTRUCTIONS
9.Total well depth below land surface:
For nmltiple wells list all depths if&flbrent(example-3ta)00'and 2(aJ00') Submit,this G\1`-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ��� (ft-) 24a. For All Wells: Original foal to Division of Water Resources (DWR),
If enter level is abmv casing,use"-' `�If Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 fIn) 24b.For Injection Wells: Copy'ito DWR,Underground Injection Control(JUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.\Nell construction method: ti 24c.For Water Supply and Open Loop Geothermal Return\hells Co to the
(i.e.auger,rotary,cable,direct pus};etc.) county environmental health department of the count)'where installed P.
[FOR\\'ATER SUPPLI'\\'ELLS ONZY 24d.For\stater Wells producirtE over 100 000 GPD•Co to D.Yield(gym) Method oftest AIr Permit Program,1611 il4SC,Raleigh,NC 27699-1611CCPCUA
.Disinfection type: HTH Amount: l �ti5 i
Fora GIN`-1 North Carolina Department of Environmental Quality-Division of Water Resources Reused 6 6'_018

GASTON COUNTY DEPARTMENT OF HEALTH& HUMAN SERVICES
ENVIRONMENTAL HEALTH DIVISION
991V- HUDSON BLVD.,GASTONIA,N.C. 28052
- 704-853-5200Ay
Permit Void After 60 Months WELL INSTALLATION OR REPAIR PERMIT
PERMIT 1 1 603
Owner/Applicant: Date:
C64 M3�Mailing Address: Phone:(H) C'?��t>r1i. ' 51L (W)
Lot Area Subdiv islon'Mark Lo # Block#
PROPERTY LOCATION' a Ntj
Signature of applicant or authorized-agent
Type Size Depth Casing,Depth
Casing Type Static Level Yield Grout
Grout Date Contractor/Driller
SITE 5KETCH�=-No Scale
Distances Masi Conform
To`Local/State Codes:•
Most Common Examples Are:
1. Water Tight Sewer Line...... 50: g2�'
2. Ground Absorption
Sewage System................100' `
•3. Building Foundations-......- 25'
PID# ,
PIN#3 {
GRID#, 1-4-
This permit does not relieve
the well/septic contractor
from complying with an
Gaston County and/or North
Carolina Laws,Rules,
Regulations and Ordinances. fro'
sy3
F
WATER SUPPLY INFORMATION:
Well location,installation and protection must meet state and local regulations,and must be inspected and approved by representative '
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 County E • onmental He tl S lion(704-853-5200)for bacteriological and'inm genic water
samples.
ll
DATE ISSUED EHS
DATE WELL HEAD . SECTION COMPL E S
FEE PAID S AC� _ DATE RECEII'T# IP#
DATE SAMPLES COLLECTED DATE ACTERIOLOGICAL RESULTS' 'RESULTS
Original White: Health Department Pink: Inspection Dept.. Yellow: Applicant Copy