GW1--02646_Well Construction - GW1_20240501

WELL CONSTRUCTION RECORD(GW-1),, For Internal Use Only:
1.Well ContactoInfomation:
Kyle C. Shaw -
1J.WATER ZONES I
Well Contractor Name FROM TO I DESCRIPTIO\
4521-A 1.15 ft. \to ft I �S girl
ft 11
i C Well Contractor Certification Number
15.OURAdvanced Well Drilling, LLC FROMTI ICTOAS�G(for I DLA-METEReIIs)I THI T (iHICKNESS
MbTERL4L
Company Name a ft �� ft I 6 in. I Heavy I PVC
c7�/ 16.INNER CASL\G OR TUBING(geothermal closed-loop)
2.Well Construction-Permit=: J-3 V 3 5- FROM I TO I DIAMETER L THICKNESS I MATERIAL
List off applicable well construction permits(Le.GIC.County;Stare.Yariance.etc.) _ ftI Ce in.
3.Well Use(check well use): ft. ft. ! in.
Water Supply Well: 17.SCREEN
❑Aoriculhiral FROM I TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Municipal'Public ft ft in
❑Geotherirtal(Heating/Cooling Supply) C'IResidential Water Supply(single)
ft I ft. is
❑hldustrial/Commercial DResideniial Water Supply(shared)
❑Irrigation is.GROUT I 1
❑Wells>100.000GPD FROM 1 TO I MATERL•1L ' i EMPLLCE:\IE'TMETHODSA IOIWt
Non-Water Supply Well: a ft I ) ft Bentonite I Poured
❑Monitoring ❑Recover' a. I ft I -
Injection Well: - '
❑A uiferRecharge ft. I ft. I
❑Groundwater Remediation •
❑A ttifer Storage and Recovery 19.SAND/GRAVEL PACK(if applicable)
qDSalinityBarrier 1 FROM I TO' I \LATEItL.L I EMPLACEMENT METHOD
DAquifer Test ❑Stommater Drainage ft, I ft.
❑Experimental Technology ❑Subsidence Control ft I ft j'
❑G:othenmal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets ifnecessarv) .
t7Geothemtal Heaii)Ig/ FROM I TO I DESCRIP ON(color.hardness salUrocktype.Rain size.etc)
( =Cooling Return) OOther(eti-nlain under 421 Remarks)
r �/ a It is 6 ft lx(-l�Ut tQ
1.Date Well(s)Completed:3 a2v- ( \,\'ell ID I �Q ft I �/j ft fSo l-�c�L�4-
Sa.Well�jocattow} (' --i ft* O 3 ft I ( c t ;5C CO i-K-
-D�.t'f L4C��1�es CS G.O' Ae2 3 it /65- It I &Io\d (-01.r-
Facility/Owner Name Facility D=r:ifapplicable) ft I rt. ',L
/334 G - 4 VA. S.cJIaol l I , C iflrt;o iVt1 ft. I ft .
Physical Address,City;and Zip t ft. ft. I a-` k• r. �(? i s r
G"l i`Ot 21.REM'LARLS MAY v- I [U L i
County Parcel Identification No.(PIN')
5b.Latitude and Ion lode in de ees Ireft::-- . P-`-^-."• ?i,
g1 /minutes/seconds or decimal decrees: D..c LU.:r
(if well field.one iat/long is sufficient)
S 22.Certification:
� Z� 7 ,rq is 0,1SV ° �S3q. W P• H 3 1// G/
q.Is(are)the well(s): nPer manent or DTemporrtr si_a,a�e of Ce tales Well Contractor Date
By signing tirisjbrnt.I hereby cert(fi•that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: CYes or i2 o 15.=_y'C._C 02C.0100 or I5.4,\CRC 02C.0200 Well Construction Standards and that a copy
11 this is a repair;jilt out known well construction ir_tomtanon and a;pkrin the nature of the ei lids record has been provided to the well otuner.
repair under#2/reillarkS section or on the bag:-ofthisArm
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geother l Wells having the same You may use the back of this page to provide additional well construction info
construction.only 1 OW-1 is needed. Indicate TOTAL\'UMBER of yyzlls (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: /
d5 r
For multiple wells list all depths il uftferent(=ample-3;4200'and_tn_00') (tt.)
Submit this GW-1 within 30 days of;well completion per the following:
// / I
10.Static water level below top of casilig: �7 fL 24a. For All Wells: Original form jto Division of Water Resources (DWR),
If tinter level is above caring,use"=' ( ) Information Processing Unit,1617 MSC.!Raleigh,NC 27699-1617
11.Borehole.diameter: 6 (m.) 24b.For Injection Wells: Copy to DWR.Underground Injection Control(RUC)
/ Program,1636 MSC,Raleigh,NC 27695,,-1636
12.Well construction method:.y(r'J2-, -
(ie.auger,rotary,cable,direct push,.etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100.000 GPD:Copy to LAIR CCPCUA
13a.Yield(�Rgm) o Method of test: r Air Pe,mit Program, 1611\•ISC,Raleigh,r\C 27699-161I
13b.Disinfection type: Hl-J-I Amount: I f bs `
i
•
Na-b CaroIna Department of En yironmental Quality-Division of Water Resources I

is
GASTON COUNTY DEPARTMENT OF HEALTH&HUMAN SERVICES
. ENVIRONMENTAL HEALTH DIVISION
991 W.HUDSON BLVD.,GASTONIA,N.C. 28052 ' :
704-853-5200
Permit Void After 60 Months WELL INSTALLATION OR REPAIR PERMIT
� PEniiigt # 1 3835 -
Owner/Applicant: Pi O?. ^))Surd_Qiaf\(` Date: ��-a 3 •
•
Mailing Address: Phone:(H) ''0•.., - '{W) r�
Lot Area ,6 Subdivision/Park Cy D' On.A Lot# R Block# tL)
PROPERTY LOCATION 1'.: cl eiCk'a"s -1VN7s C (i)( . '
- Signature of applicaut or authorized agent
Type Size . Depth Casing Depth
Casing Type Static Level Yield Grout
Grout Date Contractor/Driller
SITE SKETCH—No Seale
Distances Must Conform
To LocnUState Codes. 1 2 e, '
Most Common Examples Are:
1. water Tight Sewer Line 50' • ,
2. Ground Absorption 5''0 •
Sewage System. —MO' I
3. Building Foundations 25' 1). 1 �v ��
;' "I?..v r .
PliNit . . ' .-.• ,-.. T-)4/ /3k) /
GRID# �.. '.< ..... /
2-5 A 'Du i\a(.n /
This permit does not relieve \ L./ . :Zvi •
. the well/septic contractor yt,k GaC.14--' L A
from complying with all \\__ v �t�, 7\ 1
Gaston County and/or North T C`P"'"t ` �—t
Carolina Laws,Rules,
Regulations and Ordinances. / K ✓U us - i 75.,
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7- C G -iiG
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WATER SUPPLY IN FORMATION: • I
✓ Well location,installation and protection must meet state and local regulations,and must be inspected and approved by a representative of
the Gaston County Health Department before any portion of the installation is put into use. ,
o The siting of the well by the Health Department staff is to provide protection from IINOWN possible sources of contamination. No quantity
and/or quality of water is guaranteed at any site by the Health Department.
O After the well is in service,contact the Gaston County Environmental Health Section(704-853-5200)far bacteriological and inorganic water
samples.
DATE ISSUED + 2 0 2 2. MIS NA. __--=
DATE WELL EAD NSPEC ION COMP ETE . --EHS. - :
FEE PAID$ , �� -DATE Vv" n• RECEIPT# 1, 1-.- ^0 E IP#ZaK0
DATE SAMPLES COLLECTED DATE OF BACTERIOLOGICAL RESULTS RESULTS
Ori6i+)al White: Health Department Pink: Inspection Dept. Yellow: Applicant Copy