GW1-2021-06950_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Michael W. Shaw 14.WATER ZONES
FRONT TO DESCRIPTION
Well Contractor Name ft. ft.
'3232 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multl-cased wells OR LINER !f n livable
FROM TO DIA,1lETER'� THICIiti FSS MATERIAL
Advanced Well Drilling, LLC U ft. ft. 6 tn. I Heavy PVC
Company Name 16.INNER CAS KG OR TUBING(geothermal closets-loo
FROM TO DIAM TER THICKNESS MATERIAL
2.Well Construction Permit#.- � ft. ft. in.
List all applicable well construction permits 6.e.County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAPIETER SLOT SIZE THICKNM MATERLIL
ClAgricultural OMunicipallPublic ft. ft.
OGeothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. tn.
❑Industrial/Commeroial ❑Residential Water Supply(shared) 18.GROUT
FRONT I TO MATERIAL EMPUICF.MENT METHOD&AIti10t N'T
❑(rri ation ft- g2D iL Bentonite Poured
Non-Water Supply Well: ft. ft.
OMonitoring ClRecovery
Injection Weil: ft. ft.
C1Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if a livable
FROM TO MATERLIL I EMPLACE6lENTNIETHOD
OAquifer Storage and Recovery ❑Salinity Barrier ft. ft,
OAquifer Test C IStorrmvater Drainage
ClExperimental Technology OSubsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTraeer 4 FRONT TO DESCRIPTION color,hardness.sailfrock tive. to size,etc
OGeothermal(Heating/Cooling Return) pother(explain under#21 Remark) LT ft' t, ft'
(�° � 0 It. f- ft r
4.Date Well(s)Completed: r--! Well ID# t
rL ft. jt� IL
! ant or-cV dt
5a.Well Locations ft.
Iz15' 3 96
yco* H,�� &A&I iQ ft. is ft. t�tiC -lf k
Facility/Owner Name Facility iD#(ifapplicabie) ft. 4f-i6 rc. O+^^
N`
Physical Address,City,and Zip Q .yrIa�.�t/ T 21 REn1ARKS
�aW IP�i .LN�SrI fJ7J(� MAY X r
2021
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutestseconds or decimal degrees: 22.Ce�'�ation: Oibll Processing Unit l
(iCweii field,one laUlong is sufficient) FJ/r�i1�" `��2 r ��:;�•fl —,i t�1
is g�po N 1.S'7j 3 b W L •J
Signature ofCenified Well Contractor pate
6.Is(are)the well(s): OPermanent or CITemporary By signing this form,I hercbv serf f<,drat the well(s)nns(mere)constructed in accordance
with 15.4 A'CA C 02C-0100 or 154 A'CRC 02C.0200 Well Construction Standards and drat a
7.Is this a repair to an existing weli- Oyes or I31Va copy of this record has been provided to the aeil owner.
If this Is a repair,fill ors known well construction information and explain the nature of tine
repair under:21 remarks section or on the back ofthisforna 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
9.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For tmdtiple injection or notr azrter srpply welts ONL I'srith the same construction,rou can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 4 �/7� (ft.) 24a. For All Welts: Submit this form within 34 days of completion of well
For nnrttiple wells list all depths ifdiereni(evanple-3@/00'and(�2 Cat 100) construction to the following:
10.Static water level below top of casing: l A (f-) Division of Water Quality,Information Processing Unit,
If " �utrier lael is above cashrg,use"_ � 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 248
{_ �_ above, also submit a copy of this form within 30 days of completion of well
12.Welt construction method: A trtr" � ``" construction to the following:
(i.e.auger,rotary,cable.direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Attleigh,NC 27699-1636
13a.Yield(gpm) _ Method of test: Air 24c.For Water Sunoh&iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 34 days of
13b.Disinfection type: HTH Amount: /)bs completion of Weil construction to the county health department of the county
where constructed.
Forts G%V-I Noah Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

Drell � my Health ep* artrl a -. 2345 Morganton Blvd. Lenoir NC 28645
t 4"
Well Construction Permit. Page Gf, .: P:[phone] Fax:[phone]
ev+r WeIIM=-. - Repair ;, 3 Aban anment ;C'PIN# ) t? WP# c
;d to: Cp} l-flC. Subifivision; k lot No. Section:.
tress of t e pro erty: - e; Lot size: 4. Im (sq.Ft./ cre) ,..,
ilrections to site: ��ahlanas $ A -T-
A.
Fac(iity vie- is to serye: t t _ Septic IP#: S I I
Properties this well is to serve: -� Date septic installed:
This permit is valid for a period of five years except that 11 may be revdfced at any time if it is determined that there has been a material change in any fact
or circumstance upon which the permit is issued. Final well head construction must be ins ected and approved by CCHD before a certificate of
occupancy is granted or the well is placed into service. The location of the well indicated by CCHD is to provide protection from possible sources of
contamination. Flow volume weltyield)is NOT Suaranteed at an site by CCHD.
Applicant/Legal Representative Signature: Date:
;CGS 87-98.4-well pumps can only be installed by: _ :,
1)Well Drillers,2)Homeowners,3)ONLY plumbers with doarrientat o continuing education covering well seat installation with in the last two years
i
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,E- AC X
U ` A 14
of To Scale 3 .: ; °1
r....: . "' Separate as-built attached
The well driller must call CCHD beiwa;8- m to schedule grout inspections Drillers must 4eriflrall required separations before drilling
the well. if the weiidri!!er is:tanatte to mai tarn required separations,contact CCHD at(828}-426-8579 before drilling the well.
....
1)Perinit Issued: y ,:_ . REHS#.1 9 1 Date b eZ
2}gout Inspected: REHS#
. Date
OR (j. Contractor certification for grouting not witnessed;by CCHD (2C.Q""305)
Grout- Depth: ;(ft.) Type: Method: Driller Company:
Casing li e: :;;.: Diameter:_ (n De Individual Driller: Cert#
3)Certificate of Completion- IREHS# Date
Well Head Casing Ht.: (in) E7 Port/Vent ❑ Well Seal o Threadless Sample Tap ❑ GW-la or GW-30
Weti i
i
0107J 2 "Li Date: De th (ft.} Yield ( m} Static H2O (ft.
ump ate: I Depthump Installer: y e
A)Water Samples Collected: IREHS# jDate
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