GW1-2021-06525_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only
I.Well Contractor Information:
Kyle C. Shaw 14.wazERZONES
a 'r
Well Contractor Name �Be; FROM TO DESCPaTION
4521-AC} '`� `L 7J�~ �9
A
NC Well Contractor Certification Number �\.J ��'` `
Advanced Well Drilling, LLC PAL {����' °� FRO„t'TER To11G(formMAMETEReIIs ORTmLL ifa li IATERL4I
ft. S� ft. 6 in. Heavy PVC
Company Name
0 16.INNER CASING OR TUBING eothermal:ciosed-loo
2.Well Construction Permit#:��01,�� ,.;���� FROat To DIAIMETER THICKNESS l\fATERLII.
List all applicable well construction perndts(i.e.1t7C.Counfi. tare,Variance,etc.) M ft. 1.
3.Well Use(check well use): fL ft
Water Supply Well: 17.SCREEN
FROM TO DLAMETER SLOT SIZE THICIuMS IMATERIAL
0-Agricultural ❑lklunicipal/Public ft. (L in,
❑Geothermal(Heating/CoOling Supply) i9Residential Water Supply(single) M ft in.
❑Industrial/Coinmercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100.000 GPD FROM To MATERLAL E'T"ACEMENT METHOD&1LUOMN7
Non-Nirater Supply Well: 0 fL n Bentonite Poured
❑Monitoring ❑Recovery_ ft ft
Injection Well:
❑Aquifer Recharge ❑Groundttiater Remediation ft. fL
❑Aquifer Storage and Recovery ❑Salinity 19.SAND/GRAVEL PAC Kda licable
Barrier FROM TO I MATERIAL EMPLACENIVU aIETHOD
❑Aquifer Test ❑Stortimater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Heating/Cooling Rettim) ❑Other(explain under T21 Remarks) FROM TO DESCRIPTION(color hardness 9DIUrock type,gnin size,etc)
fL S 0 fL Otr4 S'4
4.Date Well(s)Completed:7_9��� Well ID# 5S B- c5'-7 ft. � C-0,,
5a.Well Location: tt C
Mey-
A-A)BGK �O lezc q rL I-*N !z� Cats,
Facility/OumerName L �i3O Facility 1Dr(if applicable) it ' S ft
I���,Kt1� it. M
Physical Address,City,and Zip M %
�L 21.REMARKS
County Parcel Identification No.(PINT)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient) 22.Certification:
.6 a qri 3t Q'q�tq W
6.Is(are)the well(s): LtPermanent or ❑Temporary SignaluVe of Certified Well Contractor Date
Bt,signing this forn4 l herebP certify that the well(s)was(were)conttntcted in accordance with
7.Is this a repair to an existing well: ❑Yes or f No 151.MCAC 02C.0100 or 154 NCAC 02C.0200!fell Constniction Standards and that o cop),
If this is a repair,fill out known well construction information and explain the nontre of the ofthis record has been provided to the sell oxorer.
repair under 31 remarks section or or,fire back ofthis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal\4ells having the same You may use the back of this page to provide additional htiell construction info
construction,only i GIN-1 is needed. Indicate TOTAL NU1-IBER of hells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBNIITT.AL]INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For mrdti le wells list all depths r' di different team l-3L 2 �C Submit this GNV-1 within 30 days of well completion r the following:
P P .f .�' ( p 00'and_a,100') P per �
10.Static water Level below top of casing: �� (ft 24a. For A➢ Wells: Oriainal form to Division of Water Resources (DWR),
Ijt+nter level is above casing use
Information Processing limit,16171\4SC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (m) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
`' �{{ Program,1636 MSC,Raleigh,NC 27699-1636
12.�Ve➢construction method: �� B�CTTit<.�� 24c.For Water SuDDly and Open-Loop Geothermal Return Rte➢s:Copy to tie
(ie auger,rotary,cable,direct push,etc.) county environmental health department of the county u4iere installed P.
FOR WATER SUPPLY"M ELLS OItZ1': 24d.For Water Airells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) r`� Method of test Air .Permit Program,1611�4SC,Raleigtil i\tC 27699-1611
HTH i
13b.Disinfection type: amount: I
t
i
rcrin Gtv-1 North Carolina Department of Environmental Quality-Dnision of Water Resources ge.,eta tip__,:s

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