GW1--03050_Well Construction - GW1_20240520

WELL CONSTRUCTION RECORD (GV�r 1) For Internal Use Only:
1.WellContractor information: 1
Kyle C. Shaw •
14.WATER ZONES I
Well Contractor NameFROM70 I DESCRIPTION
4521-A r n• ` ft r j
ft. n.
\C tVell Contractor Certification Number
Advanced Well Drilling LLC 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO I DIAMETER I THICKNESS I MATERIAL
J ft ;3 ft 6 in• I Heavy PVC
Company Name
2.Well Construction Permit=• ' a r i r- )/ 16.LN_NER CASING OR TUBING(geothermal closed-loop)
` OCj r.O0&3"• /f 3 FROM I TO I DIAMETER 1 THICK•IESS I MATERIAL
List all applicable well cotutnrction permits(Le.(.7C.Co;u_ State,l'atiantce.erc.i ft. ft. I in. I
3.Well Use(check well use): ft. ft I is I I Water Supply Well: 17-SCREEN
CI Agricultural FROM I TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
QMunicipal-Public ft. I ft. in. I
❑Geothermal(Heating'Cooling Supply) !°iResidential Water Supply(single)
ft I ft in. I I
Dhtdustria[iCommercial °Residential Water Supply(shared)
1S.GROUT
❑Itrisatiotl
❑Wells>100.000 GPD FROM I TO I .)LATERLAL I EMPLACEMENT:METHOD..•A IOITT
Non-Water Supply Well:
❑\.[on;toritta ft I ? ft- I Bentonite Poured
°Recover I). ft.
Injection Well:
°Aquifer Recharge °Gn• fs.
round�tater Remediation
❑AquiFzr Storage and Recovery 19.S-.ND/GRAVEL PACK(if applicable)
°Salin t Bather I FROM 1 TO I MATERIAL E)IPLACE)IENT METHOD
DAquifer Test ❑Storntt.ater Drainage I ft ft.
°Experimental Technology °Subsidence Control ft. ft.
❑Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
°Geothemtal(Heating Coolie Return) °Otitis(e lain under 721 Remarks) FROM I TO DESCRIPTION(color,hardness.sod/rockrtpe.Vain ate.etc)
fL 25
ft- nrr�l-j
n .fYl
4. Date Well(s)Completed:e/`/f-as Well Ilk ft S-,-.3 rat
2 ,'
S )1.-v-A -ccre� rxiL
Sa.Well Location: kc lk�� � 3 3 ft 50 5 ft.( t„�,i i-1,1lo;J /,,,,Li;.� C �-,,, rat fL I 3 `i
Facilitv'Owner Name I Facility)Dc(if applicable) ft ft
aU I 13rt+ C• R,,,n f�--, C�.1 ..) hk �) i>J 2 ft. ft.�
Physical Address,City,and Zip j ft ft. I ';1 } 0Q /{
JbaA 21.REMARKS
County Parcel Identifcation No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal decrees:
(if well field one lat/lone is sufficient)
22.Certification:
3S. 6sct all'I? N - vI-475/t,5752_ «- r AL
6.Is(are)the weU(s): QPcrmarient or CTempomal� Si•aa:tte of Ce itied Well Contractor Dote
.3vsigning thisjbrnz I hereby centJ}•that the welts)was(were)constructed in accordance with
7.Is this a repair to an existing well: G Yes or l No /5.4,FC:C 02C.0100 or 1 S;A'C1C 02C.0200 Wee/Construction Standards and that a copy
If this fs a repair,Jill out know t well construction information and at-clam the nature of the of this record lets been provided to the well owner.repair under 421 n entarix section or on the hack of this.form.
23.Site diagram or additional well details:
8.For Gcoprobe/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 I G -1 is needed. Indicate TOTAL NUMBER of wells (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: )©�j
For ntaltiple wills list all depths ifdiferent to:ample-_:a:200'and_.4 i r J•, (ft.)
Submit this GW-1 within 30 days of well completion per the following:
2 la. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing: 30
If tinter level is above caving,use'= Aft) Information Processing Lnit,1617 MSC,Raleigh.NC 27699-1617
11.Borehole diameter: 6 Cm) 24b. For Injection Wells: Copy to DWR. Underground Injection Control (ILC)
Program. 1636 MSC.Raleigh.NC 27699-1636
12.Well construction method: A'.t- ;,{„,c-y
(ig.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 OOZY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR.CCPCUA
13a.Yield(gpm) c� „.- Method of test: Air Permit Program- 1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection t<pe:)t HTH Amount: ' 1 6 ,
.--_a-_lina Department of Environmental Quality-Division ef Water Resources