GW1-2022-01602_Well Construction - GW1_20220201

FELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kyle C. Shaw 14.R:9TERZONES
FROM TO DESCRIPTION
Well Contractor Name � ��
4521-A ft. rL
NC Well Contractor Certification Number
Advanced Well Drilling; LLC 15.Ot3TERCASIi\G(for multirasedwells ORLLVR tCa livable)
FROIi TO Di 1lIETER' TF�TCl��'ESS 1LATERL-1L
Company'Name fL 6 `" Heavy I PVC
j,f 16.UNINKER CAS11%OR TIIBING geothermal closed-loo
2.\Nell Constivction Permit r: 9 ` FROM 70 DL-LIIElER 7HICIvYFSS I NL4TERLIL
Lust all applicable::rli corrstrucnar penntits(i.e.G7C,County;State,i•"orianrce,etc.!
rL fL In.
3.Well Use(check well use): fL fL to
Water SupplyNell: 17.SCREEN
FROM TO DLAMETER !SLOT SIZE THIC I MATERIAL
❑Aericultural ❑vlunicipal Public fL fL in.
❑Geothenual(HeatinJCooline Supply) nResidential A'ater Supply(sing-le) fL rL in.
❑bidustrialiCommercial ❑Residential Water Supply(shared) 18.GROUT
01nitaatiotl ❑XVells>100.000 GPD FROM TO \LATERLAL E-NIPLACEAIE\7.\tMIOD&.L•\tO11T
i\on-WVater Supply Well: fL 3L5 fL Bentonite Poured
❑-h•foriitoring ❑Recovenv M ft.
Injection Well: fL fL
❑aquifer Recharge ❑Groundnater Remediation 19.S.AIDIGRAVELPACIk(ifapplicable)
❑Aquifer Storage and Recover, ❑Salinity Barrier FROM To \LLTERL-1L I EMPLACEMENT METH0D
❑Aquifer Test ❑SIonnttater Drainage fL fL
❑Experunental Technology ❑Subsidence Control Is. Is.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional'sheets ifnecessary)
FROM TO DESCRIPTION(color.hardness,sollfroc6tr e,grain size.etc)
❑Geothatnt¢1(HeatinJCoolinga Return) ❑Oilter(z�plain under=21 Remarks) FROM
4.Date Well(s)Completed: H '2,1 Well ID= 10 It. QS fL
Sa.Nell Location: j iL 3 2 R' ��
Q6-_SA d f- fL
Facilitv'OttrerName Facility IDc(ifapplicable) -:!)qCL VO tG Ha{-d y S1bzJ
L44S RM K. RJ_ R.�.Son J L 2�?LSI L40 a. '5fL L
n A.
Physical Address,Ciry and Zip
C&JJLJC1' 21.RENLARKS
FT a County Parcel Identification No.(Pik)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifivell Feld one lat/long is sufficient) 22.Certification: ':e
1
6.Is(are)the well(s): 0-Permanent or U.-Temporary signat0c of Certified IN-VI Contractor Date
3t si¢»in¢thii form,I herebt•cero,that the xell(s)tsar(is-ere)constructed in accordance i+iih
7.Is this a repair to an existing well: C.-Yes or &No 15.d�rC;C 02C.0100 or 1 S4I krCAC 02C.0200(rel(Constnrctiar Standards acid that a cola,
t0his is a repair,fill out known smell construction i 1tbrtn Lion and explain the nature of the ct tl is record has been provided to the sell oxmer.
repair underT21 remarks section or or rite hack of?his forms. 23.Site diaal'am or additional well details:
You may use the back of this page to provide additional tall construction info
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sauna
construction,only I GtAr 1 is needed. Indicate TOT.kL NN LI4BER of nzlls (add'See Over in Remarks Box).You may also attach additional pages if necessar--.
drilled: '
24.SLBINIITTAL]INSTRUCTIONS
916ial well depth below land surface: _ q0 rb (ft•) Submit this GIV-1 within 30 days of well completion per the following:
For ntuul6ple wells list all deptls ifditje nr tent(exaole-.i,m200'and_:a100'1
10.Static water level below of casing: (�O (ft) 24a. For an Rrells: Original for ;to Division of Water Resources (DWR).
If sszrter level is some casino use =' Information Processing Unit_1617\•ISC.Raleigh\C 27699-1617
11.Borehole diameter: 6 (m) 24b.For Injection Wells: Copy to DR'R,Underground Injection Control(IUC)
` Program_1636\1SC.RaleiJi.\rC 27699-1636
12.WWI cotuhvcdon method:
(ie 24c.For Water SuppLT and Open-Loon Geothermal Return R'ells:CoPy to the
(,ie auger,rotary,cable,direct push,etc.) r count)-environmental health department of the county ttiteFe installed
FOR 1VATER SUPPLY NNTLLS ONLY: 24d.For«rater 1Vells panducine over 100,000 GPD:Copy to DWR.CCPCUA
13a.Yield(_gjtm) r-L Method of test: l r
Permit Program. 1611 yISC,Raleigh.\'C 27699-1611
13b.Disinfection hpe: TH Amount: I 195
N:crth Carolina Department of Entaronmental Quality•-Division of Water Resources

a M
F.> ,
Caldwell County Health Department 23451vlorganton Blvd. LenoirNC-28645
Well Construction Permit Page of P:(828j 426-85�9 'fax:[phone] ,
New Well Repair AbandonmentINC PIN i1 -14*f a y WP- (4 —"WiNSt�irip
Issued to: o r} is Subdivision: — lot No. -- Section:
Address of the property: AiU d r Lot size: 9(o,y (sq.Ft.J
Directions to site: r
Z 1 i 'S �o 'P UIR M+)J R14 ; - -11 n �[) -Ptne A{rid &4' L o 4 t 5 o n L W4
Facility well is to serve: a qp 5t A ct 5 jSeptjcIP.,#: CAL+l to l
Properties this well is to serve: 4 L4S pin tAT& Rd I Date septic installed: i
This permit is valid for a period of five years except that it maybe revoked 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 inspected and approved by MD before a certificate of
oaupancv is granted or the well is placed into seance. The location of the moll indicated by CCHD is to provide protection from possible sources of
contamination. Flow volume(well yield)is NOT guaranteed at any site§y CCHD.
Appiicant/Legal Representative Signature: Date: J0. J J
NCGS 87.98 4-well pumps can only be installed by:
1)well Drill rs,2)Homeowners,3)ONLY plumbers with documentation of continuing e Jucation covering well seal installation with in the last two years
*Re i t At P-o'
s � aa5'
L , 100
Cb ,
Not To Scale. 0 Separate as-buiit attached,
4 The well driller mustcall CCHD between 8-9am to schedule grout inspections. Drillers must verify all required separations befog eldriiling
r
the well. if the we driller i4AAinable to maintain required separations,contact CCHD at(828)-426-9579 before drilling the well
1)Permit Issued; ,� REHS# , JCJ I Date l 1
!)Grout Inspected: REHS# Date
i' OR 0 Contractor certification for grouting not witnessed by CCHD (2C.0305)
Grout Depth: (ft.) Type: Method: 1 Driller Company:
Casin Tv e: Diameter: in Depth: [Individual Driller. Cent#
3)Certificate of Completion: REHS tt Date
Well Head lCasing'Ht.: (in) Ll Port/Vent '! Weil Seal i 7 Threadless 5ampli;Tap 1 j GW-1a or GW-30
Well Plate .01071(2) M Date: IDepth (ft.)Meld (gpm)Static H20 (ft.)
Pump Plate M- mpnstaleg ri
Data
4)Water Samples'Collected: RE1.15 n r