GW1-2021-00185_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:
pp� W.
KMWATERZOIWSNES Michael VV. Shaw DESCRIPTIONWell Contractor Name � fL 3232 ft. S ING for muiN ca ed wells OR LINER(if a ticable)
NC Well Contractor Certification Number DLI,IIEINMTERLILAdvanced Well Drilling, LLC y0 tt. s in• hiea PVC
Company Name 16.INNER CASING OR TUBING( eothermal closed-loop)
y � FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
ft. ft. In.
List all applicable hell constntclion permits(f.e.Carmnt State,i arionce,etc.) ft ft. in.
3.Well Use(check well use): 17.SCREEN
FROM TO DIAMETER !SLOT SIZE A THICKNESS hLITERML
Water Supply Well: ft• g• in.
❑Agricultural OMunicipaUPublic
(L ft. in.
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)
18.GROUT
❑IndustriaUCommercial ❑Residential Water Supply(shared) FROM TO ALITERLIL EMPL ICEDIEIIT METHOD&1110UNT
❑lrri ation ir. 0 ft. Bentonite Poured
Non-Water Supply Well: ft. ft,
❑Monitoring ❑Recovery
ft. ft. i
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO I MATERIAL I EMPLACEMENT\METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
OAquifer Test OStormwater Drainage ft. fL
❑]experimental Technology ❑Subsidence Control 20.DRILLING LOG attach add(tional'isheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,Hardness.soiVroek Iv a in size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0
it. 5 rt.
o ft.
4.Date Well Well ID#s)Completed: '4_0 ft• gS ft.
5a.Well Location: it. ft.
Facility/OOwnerrName '1 r� - , �• Facility ID (ifapplicablee))r, ft. ft.
•�v
�7 f 6 Qt�O U;Iso✓t Kam. [a..S�niet. N�� � ft. ft.
Physical Address,City,and Zip 21.REMARKS
G'X0o n 1
County Parcel Identification No.(PIN) I +%i-mo(iY-i) i f`' ' m`
:V ,S n_C)I
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Ce J ation
(if well field.one latklong is sufficient)
-7 S N
a I Date
Signature of Certified Well Contractor
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this forrtt,I hereby cert fi•that the eell(s)nun(were)constructed in accordance
widt 15.4 AVAC 02C.0100 or ISA NCAC42C.0200 11'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No cops'of this record has been provided to the trell owner.
If this is a repair,fill our known tve7/construction information and explain the native ofthe 23.Site diagram or additional well details:
repair under T21 remarks section or on the back of this form.
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-nutersupplc wells ONLY with the same construction,volt car SUBMITTAL INSTUCTIONS
submit onefonu.
9.Total well depth below land surface: ) yL) 24a. For All Wells: Submit this form within 30 days of completion of well
For ran ltiple wells list all depths iidifferent(erample-3&000'and 2@100) construction to the following:
10.Static water level below top of casing: [ J (M) Division of Water Quality,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
if enter level is above casing,rise
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method:,L'r �o�aCi r construction to the following: f
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: {
Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) �4 Method of test: the address(es) above, also submit'one copy of this form within 30 days of
HTH completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
North Carolina Department of Environment and Natural Resources-Division of lYater Quality I Revised Jan.2013
Form GIV-1 ! p

GASTON COUNTY DEPARTMENT OF HEALTH&HUMANI SERVICES
ENVIRONMENTAL HEALTH DIVISION
991 W.HUDSON BLVD.,GASTONIA,N.C. 28052 I
704-853-5200
Permit Void After 60 Months WELL INSTALLATION OR REPAIR PERMIT �}
PERMIT# 13433
Owner/Applicant: -{ '4 � 1�t' 1 Dater
Mailing Address:
.Lot Area Subdivision/Par Lot Block#
PROPERTY LOCATION
Signature of applicant or authorized agent
Type Size Depth Casing Depth
Casing a Static Level Yield. Grout
Grout Date Contractor/Driller
Distances Mast Conform SITE SKETCH—No Scale ll
To LoeaUState Codes. F,,'r��ti i r� �J�•�-�(. �� 1 2 5 �w�d i,n
Most Common Examples Are: '6 1
1. Water Tight Sewer Line.......50' Pl A
2. Ground Absorption v
Sewage System........„.„...ieo,
3. Building Foundations.......... 25'
Pm#
_._P.IN#j55'a-•���f 2a'?NGQEss E��Ess � ,�
GRID#
rn trs Ct_
7thl'eweWs;epdc
m does not relieve
I AAA
contractor YZI '
from complying with all ,
Gaston County and/or North
Carolina Laws,Rules, \
Regulations and Ordinances.
zg
3 4
WATER SUPPLY INFORMATION:
• Well location,installation and protection must meet state and local regulations,and must be inspected and approved by a representative of t the Gaston County Health Department before any portion of the installation is put into use.
• The siting of the well by the Health Department staff is to provide protection from KNOWN possible sources of contamination. No quantity
and/or quality of water is guaranteed at any site by the Health Department.
• After the well is in service,contact the Gaston County Environmental health Section(704-853-5200)forbacteriological and inorganic water
samples.
DATE ISSUED 2V 74 EHS
DATE WELL HEAD SECTION COMPLETE ElAs-
FEE PAID$ niku ` DATE I ja RECEIPT#
DATE SAMPLES CO LL D DATE OF BACTERIOLOGICAL RESULTS �1 RESULTS
Original White: Health Department Pink Inspection Dept. Yellow: 'Applicant Copy
p ,
ff/41,7
Tj
/. i

�va.UYIl1L11JlLgg�19 PE_CfT, RItVy�� `
'1 ��11l1�� VV_
I.Well Contractorkiformacion: ForTnternal Use only: ='
Chris Morgan j
tt'ell Contractor Name 14:li'ATEIt 2pNES
3572 TO pitoAi I
nF�cturc'ioti
R. �
NC Well Contractor Certification Number ft 1
ft.
Morgan Welt Pump, lne. Is..orl rER CASING(for mutt cased tivclLs OR
COMMY Name 17tOai To D(Aa1ETER 1'r1V$R f f' Itcablo)
+t R. TEi[CIO`IFSS 11ATERIAL
// � ft. 6118 in.
Li Well plIcabruc4on Permit#:-C 33 Lh2 16.INNER CASING OR TU6t sdr21 pvc
List all appllcah/e u21!coastrrction permits((e UlC,Cotrrni.State.!'ariancG etr~J FR01t �G(eothermal closed-loo
TO DIAMETER THICItNESS
3.Well Use(checli well use); fL ft In AU ME
tattier 5uPP1Y Well: fi' ft. In.
Agricultural 17.$CRI;L"iy
oMunicipal/Public At TO DIAi11E1E1t SLOTStZE
Geoth lndusermal(Hcating/Cooling Supply) �IResidentiat Water Supply-(Single)I m It THICIrness n.LITER�
In.
Mai/CommercialIr
DResidential Water Supply(shared) ft. '"''
litigation III,GROUT.
Non-+Eater Supply W— a`' 18.Gt To
01 orlitoring itta7Etttat entf'tACEntENTAI cc HODgntounr
a rr zo
Injection Well: ORecovcry bentonite poured
ft. ft.
Aquifer Recharge
QlGmundwaterRemediation ft. ft 0Aquifer Storage and Recovery
QlSaliniry Barrier 19.SAND/GRFu L PACIt ifn lirnbtcl.
. Aquifer Test FROb7 TO
[�IStormwaterDrainage ft ATaTERrAL EIiPLACMIr-t'1--on
Experimental Technology . ft.
Geothermal(Closed Loop) 01Subsidence Control
ft. it.
Geothemtal($eatinglCooling Retwn C]ITracer
Outer(explain under 21 Remarks) 'D• To LOG(attach
DESCRIPrIOrsheets
otor,har�dacss soi°nett i e etata srec etc
FRoAI
at
�•Date i'Vell(s)Completed; �Z' til ft. a
4VeItIl3;ffl/a a-wn ►� �\
52.Well Location: a ft• 3S ft. Sr e J
3S"ft. aft.
n/a S 12a�c`
$6 ft. oc rt.!lot dtry/Owner Name
Facility
/IDp(ifapplicable) �0 tt, qO ft. f�4�
Phy5mal Addnsti,Cut},and Zip P yy•��e- ft
7G
Couniv` ! g7 f 21.REVIAlu0S y
Parcel Idcntiftcation No.(PiN) 1 '
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcil field,one lat/loue is sufficient) �7 n Y X 5�S 36 23SZ N 81• JG7 6 d 22.Certification: ()illi
7 e '?C^'' aSiClf�
-J t rds J
6.Is(are)the wells)X1- Pe �' 1;��j 1 ��Q�''��:aw.,3,0i1 • f. 2�2
rmattcnt or QlTemporary SignntureofCertifj6i11Vc11Contr�ctor
7-Is G Date
thus a repair to an existing well. 0YeS or ;No BJ's19nh?g Ibis fann.I herahj,Mrt fy that the rral!(sJ leas(were)constnrcted in accordance
ftbis is a repair,felt art knortiu 17011 construction injannation oarl erplairr 16a nmern of the c PJ'al!/r rncord'has06��prajded�a�e ue11 firmer,
repair under��/remarks sac!!on or on the back ojthis jorni C-0_00 Well Conrtntctiart Standat ix and that a
S.For Geoprobe/DFT or Closed-t 23•Site diagram or additional well details:
°°p Geothermal Welts having the some You may use the back of this page to provide additional well site details or well
co lied: Lion,only 1 G V-I is needed. Indicate TOTAL construction details. You may also attach additional pages if necessary.
drilled: ' NUMBER of wells
9.Total troll depth below land surface: �(fo SUB QTTAL D.,STRUCTIONS
1%ot-ttittlttple Is-Oils list all depths fdgerem(eranrple-3@200 a id zCi/001 (f'') 24n. For All V'ells: Submit this form within 30 days of completion of well
10-Static water level beloly top of casing: U construction to the following:
brnvterlate/isabatvcasin *,g,its, " 7 0 (ft.)
Division of Water Resources,Information Processing Unit,
11,Borehole diameter: 6 (in.) 1617 Mail Service Center,%- Ieigh,NC 27699-1617
r00 24b.lion Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: rY above,also submit one copy of this form within 30 days of completion of well
(Le.au-per,rotary,cable,direct push,etcJ construction to the following:
FOR WATER SUPPLY VaZLLS ON-L: Division of Water Resources,Underground-injection Control Program,
13a.Yield(gpm) 1636 Mail Service Center,.-Raleigh,NC 27699-I636
Method of test: air pressure
24c.For seater S°DDR'&Iniection Wells: In addition to sending the form to
I36.Disinfection type- granular the address(es) above, also submit ode 'copy of this form within 30 days of
Amount: completion 01'well construction to the`county health department of the county
where constructed.
Torn OW-1
North Carolina Department of Enyiromnental Quality-Divisiaa of Water Rcsotttocs
Revised 2-22-20 16

For Internal Use Only ' " '"""2•Well Cantractorhlforination: . _ .... ... .-- .
Chris Morgan
Well Contractor Name 14.)i'ATEft20AfES
3572 rn0141 To DESCRu'rtoN
6 ft. ft.
NC)Yell Contractor Certification Number fL
ft.
Morgan Well g pump, Inc. ts.OtIZ ;i: CASING(for mn18 cased tvcras OR rROItI TO DL11lfETER LINER(IC' ncable
Company ti�ame TtRCIM.. !—!!!- TAL
R J J Y +1 ft. ft. 6118 in.
2,Well'COnStruCfion Permit#: 16,INNER C sdm pvc
Gist all applicable u211 constrction permits(i a UIC,Cott,, State,r'arlance etc) CASING URTUBING .the cal closed
-too
rROilt TO DIAM1IETER
THICICNr- S IIATEMAL
3•Well Use(checias'ell use): ft' im
tl�ater supply Well: ft' ft. lo.
Agricultural 17.SCREEN
[ Municipal/Publie rROhl To DIANIETER : SLOTS
Qcothermal(Hcating/Cooling Supply) I&Resldential Water Su l. IL ft. In. THICIrness 5EA IAL
[�Iindustrial/Commercial AP) (single) ft
[�IResidential Water Supply ft. ;n
Irrigation PP Y(shared) 111.GROUT.
Non-Water Supply Well: r•Ron1 To
ti7ATERUL EhtPLACEN=N�'T 11L•TIIOD&ANIOUNT
Monitoring o ft. zo
Injection Well: 2�Rccovcr�3 bentonite poured
ft. ft.
Aquifer Recharge
Groundwatel-Remediation ft. ft
IAquifer Storage and Recovery []ISalinity Barrier 19•SAND/GRAVEL PACK ifa ticablc)
t- AquiferTest FRONT To[]IStonnwater-Drainage M1iaTERiaLENTPLICF.M11157_TETHOD
perimental Technology ft ftothermal(Closed Laop) EJISubsidence Control
ft. ft.
othermal QlTracer
(Heating(Cooling Return 20.DRILLING LOG(attach additional sheets If necessary)
Other(explain under�.21 Remarks) RO1i TO DESCRIM'1'i ti Color.hmdatas sail/rad:it a ara;a s�etc m
�l.D WeIIIDRate LVell(s)Completed: ( �1 I�Z,� n/a 0 ft ft.
----.---- Q it. . �
Sa.Well Location: ft. p-row,7
LeS 30 ft. -7 ft.7 Q rc�t(a r n/a -IS ft. pVft.
4kc4_c
try/otvncrNamc
Facility f (ifapplicable) ft. ft. r t.�
7 S ft. ft Physical Addn s,City,and Zip
ft. ft.
chant Clzs r` 3578 -o S"-S'S 1 21.REMARItS
Pamcl Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(ifwell Geld,one tnt/tong is sufficient)
3�• S 7 a rt 91. [1 G P)�3 l2.Certification- ,��IO°;t;SStff
�' I a;e cp�� D
W 0
6.Is(are)the wall(s) ):Permanent or r1i ., r�v t /co
[]IICmporalp Signature ofCcnii, Nell Contractor ``
7.Is tills a repairDate
to as existing well: By signing tins fo.I berebil certify that the reel/(s)tva,(were)consrnrcted in accordance
jlbis is a repair,fill oat knotvtr 1m11 constnrcrion inj nnariau and erp ain the naatre of Wfth r PJ'15ANC_C 02C.0100
I.6 00t pra or y AI to Cc,�eii Witmer,
repair
uttdcr 31 ranlanlssection or on the back ofr11krornI. C•0-QO Rlell Constnictiuu Standards and thar o
S.A or rveoprobe/1?PT or Closed-L 23•Site diagram or additional well details:
oop Geothermal Wells having the some You Iasi)'use the back of this page to;provide additional well site details or well
construction,only 1 GWi!is needed. Indicate TOTr1I, construction details. You may also attach additional pages if necessary.
drilled: � i NUMBER of wells
9.Total is-ell depth below land surface: oQ SL-BItiT>,AL INSTRUCTIONS
ra'multiple trefts list al!depriu IJLe+etm(Qrampie-3 a�3pll mtd 3�al1UD� (f 24a. For All ti'ells: Submit this farm within 30 days of completion of well
10-Stmttic crater level below top of casing: LiQ construction to the follott ing
If itwer lerel is abot=ecasing,Ise^t" (ft) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 1617 Mail service Center,Raleigh,NC 27699-1617
{in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: fOiary above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER siIPPI.Y Vl`ELLS ONL.. Division of Water Resources,Cenfer,Raleigh,NC 276994636 Underground injection Control Program,
13a.Yield(;pat) � � i4iethad of test: air pressure 1636 Mall Service
24c.For Tinter SunDly&Iniection Wells: In addition to sending the form to
I3h.Disinfection type; granular go'1 the address(es) above, also submit one,copy'af this form within 30 days of
Amount: G� completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Q=lity-Division orwatcrrtesoures ����
Revised=__016