GW1-2022-09625_Well Construction - GW1_20221021

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only: I '
s
I.Well Contractor InfoiTnation:
Kyle C. Shaw 14.ITATER ZONES
FROMTO DESCRIPTION
iVell Contractor lvame ;
4521-A
IL 'L ..
I;C Well Contractor Certification Number 1-9.OUTER CASLrG(for multi-case lyells2 OR 111%TR fif a ticihle
Advanced Well Drilling, LLC FROM TO DL\1fEfERI i THICI YFSS MATERLAL
ft. 6 in. Heavy PVC
Company Name
16.INNER CASING OR TUBING(seotherma!closed-Igo 1
2.11'ell Construction Per mit=: 1��"�I�y- FROR ft ro DL\\fEi ER Tatct�*tiss IMTERLIL
�• in.
List all applicable-ell constniction pemtits(Le.LTC.Cotuut:Stare.I orfance.etc) (�
3.Well Use(check well use): IL fL in
Well: 17.SCREEN
Water Supply
FROM TO DI.-MErER SLOT SIZ- I 0,IaTERL1L
❑Agricultural ON-funicipal/Public ft- fL 11L
❑Geothermal(Heating/Cooling Supply) C9Residential IVater Supply(single) fL ft. in.
❑Industrial/Conmrercial ❑Residential Water Supply'(shared) 18:GROUT
01nieation ❑Wells>100-000 GPD FROM TO M.\TERL1.� _ EJIPLaCE\rE\Td a:1
1ETHOD.010L;CT
Non-li'ater Supply 1Vell: ft ttti Bentonite POUM �' '�C:_'
❑\,fonitorut2 ❑Recover° ft ft.
Injection lVell: fL fL O C T 1
❑Aquifer Recharge ❑Ground\vater Remediation
2027
19.S�,.rD/GR_wELPACK(ifa licable).
❑Aquifer Storage and Recovery ❑Salhmity�Barrier FROM TO MATERLIL >, I
❑Aquifer Test ❑Stommivater Drainage fL fL CM10jam
❑Experinmenial Technology ❑Subsidence Control fL ft
❑Geothermal(Closed Loop) ❑Trader 20.DRILLING LOG(attach additional sheets if necessary)
V
TO DESCRIPTION(color,hardness soWrockts e,araln-size.etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under'21 Remarks) L/ fLt 11�. Ou
fL ..�4.Date Well(s)Completed: «'ell Ma5a.Well Location: � ft
�F i}litllonmerNa a Facilitr ID'tifapplicable)
�C�a��4A�„�r�;+ � F ts•v� .°aril��4 � __ �m�y,Iwo
}y} 'r., � R I w.
hysical Address;City,and Zip 4�os fL ft x }
T 21.RE\LUM
Countv Parcel Identification No.'3'L17
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if-well field,one lat/long is sufficienti 22.Certification:
i r7 �� t� N � i cS �Q tj I/ �1.cI� "L 13 ,
6.Is(are)the mm•ell(s): .°Permanent or GTemporar y Signer d$e of Cer¢ied Well Contractor Date
3rsLe ing thisjorm 1 herebt•cenifi'tlmt t1ic well(s)it-as(irera)constnicted in accordance ulth
7.Is(his a repair to an esistittQ well ❑1'es or \o LLd\'CIC 02C.0100 or 13.4,vC IC 02C.0200 Krell Constniction Standards and that a tort•
Ifthis is a repair,fill out known well construction information and explain time nature of tha girl is record lms beenprovided to the well.ourtec
repair under-21 rantm-i section oron the back-ofthisform
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 G11�1 is needed. Indicate TOTAL\13\1BER of wells (add'See Over'in Remarks Box).1 You may also attach additional pages if necessarV
drilled: 24.SUBMITTA.I,INSTRUCTION'S
9.Total well depth below Iand surface: DW5 (ft*) Subunit this GNV-1 within30 daps of it completion per the following:
For multiple wells list all depths ff dHlerem(exam pte-3020D'mtd 2ia100')
24a. For Ail Wells: Orisinal form to Division of 1lrater.Resources (DR'R)_
10.Static water level below top of casing: AU A) Information Processing Unit.1617\•MSC.Raleigh.NC 27699-1617
If Crater level is above casing use i
11.Borehole diameter: 6 (in) 24b.For Injection Wells: Copy to D1VR Underground Injection Control(IUC)
/ Program,1636 M NISC.Raleigh. C 27 69 9-1 636
12.Well construction method: k f 06S---r - 24c.For Water SuDDIv and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct pusk etc.) county environmental health deparhmznt of the county\'Here Installed
i
TOR 11'ATER SUTPLI'NNE LLS O\Zl': 24d.For Water Wells producitt>:r over 100,000 GPD_:Copy to DIVFt CCPCU A.
�i`� l
Air Permit Program.1611\ISC.Raleigh:NC 27699-1611
13a.1'ield G;pm) Method of test:
r }11®
13b.Disinfection type: HTH amount: 1 fj
i
`orthCarolimDepartmentof£mironmentalQualin•-DivisionofWaterResources R=a_. 5-:-=•:1z

IVH®-sEnAr®nmental-Health Division Stat8 A,,eofflce (7o4)878.5305x3456 pO4)6603625 P IT#rye
Y� PR/!/ATE®R/lY/s/lNCa WATRR WELL P . .. Per( t(trceo R�p��' A�8idtlR�1�R Lk0 -
APPLICANT/OWNER N ME: ADDRESS: PHONE- 10 4-
'DIRECTIONS TO SITE: a a L 1Nn
SITEADDRESS: D LD SUBDIVISION: SECTIO OT:
Initial Site Sketch
ROUTING RESULTS .
Total Depth
a t l Depth of Casing
Yield
Notes:
ex
0
If; irm pin.
'PE MIT CONDITIONS/COMMENTS: 0' GSiL7 2E, eez
WELL PERMIT ISSUED BY: ' DATE- 0 4q z a) (Pe6ifis valid for 5 yearsfrom date issued.This permit maybe revoked if it is determined then:has been
a material change in any fact or circumstance upon which the permit is ls,4helredell County Health Department shall in noway betaken as a guaranteethatthis well will produce water
of any particular quantity or quality orfor any amount of time. Employees of the Iredell County Health Department assume no liability forany damages either director consequential which maybe caused by this well.)
Well Con#ractor. CONTRACTOR CERT#: GROUT INSPECTION BY., DATE:
OR CERTIFICATION OF GROUT NOT WITNESSED BY DEPT. DATE: WELLHEAD INSPECTION BY: DATE:
-'WELL HEAD,INSPECTION(check when completed): GROUTTO GROUND SURFACE❑ WELL CONTRACTOR ID PLATE❑ PUMP INSTALLER ID PLATE❑ SAMPLE PORT❑
x ACCESS PORT/VENT❑ WELL SEAL❑ WELLHEAD 12INCHES/PfRESSADAPTOR8 INCHES ABOVE GRADE❑
CERTiFICATEOF COMPLETION BY: DATE: WATER SAMPLES BY: - DATE
Rtt hments:Form GW-1a(required except for abandonment)❑ Form GW-30 11 Water Sample Results❑ Plat❑