GW1-2021-06912_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells FForetrral Use ONLY:
1RR.�VI'eU Contractor Information:
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1YllCh HV Michael W. SfShaw14.NVATERZONES
FROM TO DESCRIPTION
Well Contractor Name IS� ft. �j It.
3232
NC Well Contractor Certification Number 15.OUTER CASING for Tut ti-c ed wells OR LlfCNER(if a !!cable)
FROM TO DMMETER; THIC1uNES5 ALITER3/1L
Advanced Well Drilling, LLC n. e.1Q ft. 6 'in• Heavy PVC
Company Name 16.INNER CASING OR TUBING(eothermat closed-too
FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: ��� f[. ft. 'in,
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List all applicable itell cottstntctiait permits(t.e:Cotmflt State,Variance,etc.) ft. it• in,
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROAI TO DIAMETER i SLOT SIZE THICKN EE S MATERIAL
❑Agricultural OMtmicipaliPublic ft. ft. in.
OGeothermal(Heating/Cooling Coolie Supply) EIResidential Water Supply rL ft.
( � $ PP Y) uFP Y
OlndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
_ FROM I TO ALITERLIL EAIPLACEAIENT METHOD&1'NOUNT
❑€ffi ation 0, fl• 2.D ft- Bentonite P 6ured
Non-Water Supply Well:
It. ft. 1
❑Monitoring ORecovery
Injection Well: ft. ft. i
❑Aquifer Recharge OGmundsvater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACESIUNT\METHODrt. rt.
OAquifer Test ❑Stormwater Drainage rt. fL
4
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG fattach additionallsheets If necessan
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,Hardness,solUmck tv e.Omits size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) ft. '
4.Date Wett(s)Completed: -,Veil-,Ve€€ID# s ft. 0 fL � �
ft. ') rL
5a.Well Location: It. ft.
e-4 SAc•-r ge-arlL ft. ft.
FaeilitylOOwnerrNamee 1 t 1 n f f Facility ID'
fitfapplieablle)) ft. ft. .• - a �yt'; E: t
`7 f 8 ULsO Vi JSO✓t Kid. (a..SK_aniob ty�`�• "R�' ft. ft. t c- �k✓"
Physical Address,City,and Zip 21.REMARKS
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\. mbj.n i
County Parcel IdentifiicationNo.(PIN) '�' �^ '•!'CSWi^•
i cv;l +�th.i) r.,,, try 11st11
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce tt V I em .;u !ut
(if well field,one IaU sufficient)
long is sucient) ation•
3 S. J'7 BLS .j N $f r IS i�S5 w � � - -1�;, c ,l
Signature of Certified Well Contractor Date
6.1s(are)the wel€(s): OPermanent or ❑Temporary St.signing this form,I hereby cent fi-that the irelt(s)carts(were)constructed in accordance
with 15.4 ArCAC 02C.0100 or I SA NCAC.02C.0200 R'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo cop!'ofthis record has been provided to rite is-ell ounen
1f this is a repair,fill out known well construction htforutati in and explain Ste nature of the
repair tinder 1,21 remark section or on the back ofthis forni. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple hi croon or non-isvtersupp(r ire&ONLY pith lite same construction,you con
submit oneforin. SUBMITTAL L'NSTUCTIONS
9.Total well depth below land surface: I V S {ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For iultiple ivells list all deplhs ifdifferew(erantple-3 1700 and 2@100) construction to the falloiv ing:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
If enter level is above casing.use `=" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: in addition to smiling the form to the address in 24a
above, also submit a copy of this form witk in 30 days of completion of well
12•Well construction method: A!r` &+.,a4_ construction to the follotchng: j
(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,Raleigh,NC 27699-1636
13a.Yield(gpm) :7 r-1 Air 24c.For Water Sunni}&Injection Wells: In addition to sending the form to
Method of test: the address(es) above, also submit!one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: completion of well construction to'the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality ( Revised Jan.2013
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GASTON COUNTY DEPARTMENT OF HEALTH&HUMANS SERVICES
ENVIRONMENTAL HEALTH D"ION
991 W.HUDSON BLVD.,GASTONIA,N.C. 28052 (,
704-853-5200 "I$
Permit Void After 60 Months WELL INSTALLATION OR REPAIR PERMIT
_# PERMilr# 13433
Owner/Applicant: t'` Dater lla ww
Mailing Address: Phone:(H)—At3At-(.Q1kc 31q% (W)
Lot Area Subdivision lPar _ ��--- LZ
Block#
PROPERTY LOCATION '` �t k w���• S� i OL �'C. (.y
Signature of applicant or authorized agent
Type Size Depth Casing Depth
Casing Type Static Level Yield. Grout
Grout Date Contractor/Driller
SITE SKETCH—No Scale
Distances Must Conform C
To Locantate Codes. ,`r� r.!r� `. '[ . :C } Z S S 10",(' i r+6 f C
Most Common Examples Are:
1. Water Tight Sewer Line.......541 ��.
2. Ground.Absorption
Sewage System........_...lost'
3. Building Foundations....».... 25'
PED# �
GRID#
This permit does not relieve 3'
thewelllseptic contractor
from complying with all '
Gaston County and/or North >
Carolina Laws,Rules,
Regulations and Ordinances. CILL / ,
z
� 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
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-SM)for;bacterioiogical and inorganic water
samples.
DATE ISSUED t 2Ia74 E1iS
DATE WELL AD SPECTION COMP�L�E, TE.�— E
FEE PAID$ DATE. E RECEIPT# 1 In_.
DATE SAMPLES COLLECTED DATE OF BACTERIOLOGICAL RESULTS RESULTS
Original White: Health Department Pink: Inspection Dept Yellow: lA,pplicapt Copy
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