GW1-2022-10282_Well Construction - GW1_20221114

�o'EL� ON TRUC TIORI RECORD (GW 1) For Internal Use Only:
I.Well Contractor Inforniation:
e Kyle C. Shaw
14.WATER ZONES. I
tVell Contractor Name FROM TO �f DESCRIPM's
4521-A
fL fL 41
NC Well Contractor Cerihcation Number
Advanced Well Drilling, LLC IS.OUTERCASL�IG for multi-cased wells OR LINE rlfa livable)
FROM TO DIADIElER TffiCI��ESs 1L_jTERUL
Comoan}'�amc fL
i tt 6 in. Heavy PVC
s(� •�"`� 16.INNER CASING OR TU-SING(geothermal closed-loop)
2.Well Construction Permit : �`�I !�� FROM TO DWN EfER TIIIclia`U S ILiTERI iT
List all applicable x�ll carutnectiwt permits tie.UIC.Carina;Stare,Foriance,etc-) ft fL in.
3.Well Use(check well use): fr. tt in.
lirafer Supply Rtell: 17.SCREEN
��lgriculhiral FRUM TO DIXMETER SLOTSIZE I THIMMSS I ILATERLAL
❑\•tunicipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) bResidential'lrater Supply(single) ft. rt in.
❑htdustrial/Comnieicial OResidential'rater Supply(shared)
1S.GROTIT
rOAquifar
ate `OWells>100.000 GPD FROM TO JLATERLa1. EMPUCEAIENTMETHOD S AIIOUCT
ater Supply 1Fcll: J ft- 2-0 ft Bentonite Poured
oring GRecoven
ft ft.
n'Well:
IL
ft
r Recharge ❑Ground-water Remediation
er Storage and Recovery ❑Sa]iflih Barriar 19.Sa�DIGRAt ELPACB(if a livable)
FROM TO MATERIAL EMPLACE\IEIZ'IIETHOD
r Test ❑Stomntater Drainagemental Technology ❑Subsidence Control ftftnnal(Closed Loop) OTfacer 20.DRILLL`G LOG(attach additional sheets if necessary) .
❑Geothermal(HeatulgiCoolincr Rehim) ❑Outer(a-Mlain under=21 Reinarks) FROM I To DESCRiPTIO-.�t(color,hardness sollfrocktype.gala size.etc)
4.Date 117ell(s)Completed �-2J:� «tell ID.# ft ; -z-? ft ti
Sa.lYell Location: 10 oft 5 C�-_ ft <?RN:1F uv �P r; e f
Facility/Otctter;Qame FacilityID=(Yapplicable) ft M
`� t
_� ' ( Y t�P z� ��r I#J3A�.`e b ''t� ,�i o ft ft
Phpsical Address,City,and Zip ft ft
E ou �t 21.RE\LARKS
,r✓��� 1'31�.Y�t
Couat Parcel Identification?:o.(PIN)
Sb.Latitude and Iongitude in degl•ees/minutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) 22.Certification:
6.Is(are)the well(s): CiPermanent or ❑Temporal-v Sronat&e of Certified Krell Contractor ate
Br fining dr"s torn,I hereby certifi*rlurr the welds)tray(were)constnicted in accordance uIth
7.Is this a repair to an existing wen: OYes or 8-No !Sri-CAC 02C.0100 or 15.- \rC.4C 02C.02001Yell Corfstrnction Standards and that a carp,
Ifthis is a repair.fill out hron7r well cortstntction igrormadon and etplain the cantre ofdw ofthis record has been protdded to the sell otnrer.
repair tinder=21 r attar ks section or on the back oftlrs form
33.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal\Fells having the sane You may use the back of this page to provide additional well construction info
construction,only 1 GRt-1 is needed. Indicate TOTAL\7nP IBER of walls (add'Sea Over in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SLBA•IITTAL]INSTRUCTIONS
9.TotaI well depth below land surface:` (ft.)
For multiple"'ails list all depots ife4 er ent erani Ie-3@2 2zd r Submit this GIV-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft.)
24a. For All Wells: Original form to Division of Water Resources (D1FR).
If+tuterleyel is abore casing use - Information Processing Unit.1617_MSC,Raleigh,NIC 27699-1617
11.Borehole diameter- 6 (m) 24b.For Injection Rrells: Copy to D117R,Underground Injection Control(1UC)
Program,1636\ISC,Raleigh,NC 27699-1636
(Le Wellauser,rotary,
method: 24c.For linter Supply and Open-Loop Geothermal Return llrells:Copy to the
(i.e auser,rotaq�,cable,direct push,etc.) } county environmental Health department of the county where installed
FOR 11:1TER SUPPLrr��Y"DELLS O1Z Y 24d.For Water%hells producing over 100 000 GPD:Copy to DV R CCPCliA
13a.Yield(gpm) L 0 •Method of test Air Permit Program, 1611 3ISC,Raleigh,\rC 27699-16 11
13b.Disinfection ty e: HTH i
p Amount: a h
\orih Carolina Department of Emiroirmcrital Quality-Division of Water Resource; _,,;,, c,_•„

8/9122;11:34,AW PermitToConstructAWaterSupplyW,-11 _
-Mecklenburg County Health Department x� m ti
Groundwater&Wastewater Services '�,_• �.� - t.� Ll8y--' cvs I cIJ 0-
3205 Freedom Dr:,Suite 8000 i Z f / 7
Charlotte;NC 28202
Phone:[phone]
Fax:[phone]
PERMIT TO CONSTRUCT A WATER SUPPLY WELL
w JJ
Permit#: 10013327 t 1 •Fite#: 11337B Tax Parcel#: 019-431-26
Property Owner: JOSHUA SIMPSON
Job Location Address: 15210 FRED BROWN RD
CIty1ETJ: HUNTERSVILLE State: NC Zip Code: 28078
Permit Issuance Date: 8/912022
Use of Well: Potable
Type of Facility Served by Well: House
Area of Regulated Groundwater Usage Review: NO
General Conditions of This Permit:
• Water Supply Well construction must meet all requirements set forth in the Mecklenburg County
Groundwater Well Regulations and any other applicable rules and laws.
• A North Carolina Certified Well Contractor must perform the well construction activities.
o. The permitted Water Supply Well shall be located in accordance with the attached SITE PLAN.
• Any alteration of the site (including location of structures and appurtenances) or modification in use of
the well, may subject this Permit to revocation.
• The Department will collect an initial sample of water from the Water Supply Well and analyze the
sample for total coliform bacteria, nitrate, and nitrite.A review of the analysis by the Department must
find the sample to meet the groundwater quality standards specified in Chapter 5-of the Mecklenburg:
County Groundwater Well Regulations before the Water Supply Well can be placed in service.
• The Department will collect an initial sample of water from the Water Supply Well and analyze the
sample for Arsenic, Barium, Cadmium, Chromium, Copper, Fluoride, Lead, Iron, Magnesium,
Manganese, Mercury, Silver, Sodium,Zinc, and pH.
• This Permit shall be VALID for a period not to exceed 12 months from the date of issuance.
Specific Conditions of This Permit(Check all that apply):
Grout must be.placed the full extent of the casing. ® Casing to bedrock
0 initial water sample to be taken and analyzed for(check all that apply):
Volatile Organic Compounds(VOCs) ®Semi-volatile Compounds ® Metals(Specify in Other Conditions)
Pesticides ®Herbicides ® Other(See Below)
The analysis must be approved prior to the Water Supply well being placed in service.
Other Conditions of-This Permit:
_Kim Garrett, REHS V O I, S A Sb
Authorized Agent: Print Name Owner/Legal Agent: Print Name
z 4 (I . ............. C'4,A=-71
Signalurel/ Signatu.
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