GW1-2022-01606_Well Construction - GW1_20220201

WELL-CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Kyle C. Shaw 14.WATER ZONES
Fit311 TO DESCRIPTION
Well Contractor Name IL
4521-A V
3 It IL 1S 'L M
NC Well Contractor Certification Number 15.-OUTER CASING for multi-ca wells OR LLVER f a unble
AdvancedMell Drilling, LLC FROM M
TO DIAETER THICIQ A MATERIAL.
C) fL 11.11 fL 6 in Heavy PVC
Company Name
r^ 16.INNER SING OR TUBING eothermal closed-toe
2.Vl'eIl Construction Permit#: 1 �'(� FROMM TO DIMMKIFER THICKNESS atATFRiAL
List all applicable cell construction permits(r.e.0C,Cotum;State,(rariance,eta) R D m
3.Well Use(check well use): ft. R. in.
17.SCREEN
Water Supply'Well: FROM TO I DLAMETER I SLOT SIZE I THIC104ESS 1LaTERIAL
❑Agricultural ❑AMunicipal/Public fL ft. in
❑Geothermal(HeatinglCooling Supply) InResidential Water Supply(Single) n• rL In
❑lndustriallCommercial ❑Residential Water Supply(shared) is.GROUT
0hrriaation ❑Wells>100.000 GPD FROM I TO MATERIAL ERIPLACENILNT METHOD&XMOUNT
Non-Water Supply lVell: 0fL n Bentonite Poured
❑\Monitoring ❑Recovery n
Injection'Well: n
❑Aquifer Recharge ❑Groundwater Remediation
19.SANI D/GRAVEL PACK(of applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EaiPLACEM&?T METHOD
❑Aquifer Test ❑Storinwater Drainage fL n-
❑Experimental Technology ❑Subsidence Control fL !
❑Geothermal(Closed Loop) ❑Tracer 20.DRII LLNG LOG attach additionnl sheets if necessary
❑Geothermal(Heating/Cooling Return) ❑Ocher(explain under"#21 Remarks) FROM ro DESCRIPTION(color,hardness,soturockty e,grainire m
ft. ft.
4.Date Well(s)Completed:Lo�-x- 1� Well ID# 0 n. ) IDS fL
5a.Well Location: i IL 11 1
ft.
_�e rlr'lan�.,' Ze.��i I 1 I � 138 � �1 cb
Facility/Owner Name Facility ID',(if applicable) I f p
300 Tyr, LJ'n& RZI W10's NY, 13S ft- I f6!2L
AM
t� ti n
Physical Address,City,and Zip
GAS IY�t1 21.REMARKS `
County Parcel Identification No.(PI\�
3aS
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification: r::G{ji,J1
N I �► 34 N_' -T-a
6.Is(arv)the well(s): (Permanent or ❑TemporatT Sreaa of Cued Well Contractor Date
By signing this form,I hereby certify that the well(s)wm(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 15,4 NCAC 02C.0100 or 15,4 AtCAC 02C.0200 WeR Construction Standards and that a copy
If this is a repair,fill out brown well construction iu forniation and emplain the nature of the of this record has been provided to the well owner,
repair under 4.21 rentmi5 section or on the back of this form 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having flee same You may use the back of this page to provide additional hell construction info
construction,only 1 GW-1 is needed. Indicate TOTAL`UMBER of malls (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL LNSTRUCTIOIVS
9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
Par multiple wells list all depths if different(example-3(g700 and 2@1001)
10.Static water level below topop of casing: 24a. For AIl Wells: Original form to Division of Water Resources (DWR).
(ft) Information Processing Unit 1617 Ii4SC.Raleigh\C 27699-1617
If water level a above casing use
11.f Borehole diameter 6 On.)
24b.For Injection Wells:Copy to DWR.Underground Injection Control(IUC)
Program,1636 MSC.Raleigh,NC 27699-1636
12.Well construction method: A i f^ 1`lw 24c.For Water Suoply and Open-Loop Geothermal Return 11'ells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department o the county where installed
FOR WATER SUPPLY'%ITLLS ONLY: tad.For Water�VeIls Droducin over 100,000 GPD:Copy to DWR CCPCUA
13a.Yield{gpm) otY method of test: Air Permit Program.1 11 MSC,Raleigh,NC 27699
13b.Disinfection type: HTH amount: /1 IbS
i
;=c.- ii"-i North Carolina Department of Environmental Quality-Division of lWater Resources� Revised r5-2(11 qz
i

4
GASTON COUNTY DEPARTMENT OF HFALTH 4 RUNLk�N SER-N;j
CES
ENVIRONMENTAL HEALTH l)lTt.St0,N
H s
U)SON HINII..GASTOMi.N.C. 2Hm
P&Mit Vold A MY 60 Mouths WELL INSTALLATION OR REP
AIR PERMIT
PERMIT# 1 358B
0"Iner/Applicant: Pie tv-% C L OIL
Ninifing Address: Z�k_L Ll.
1 iot Area Subdivisioll/park ' Phone:(ff; ('NV)EPS SUA_90Y-1
PROPERTAT-LOCATION '3C>QA-V - Block#
JnL-," P,1�
Siga
-17)pe size , litilre of ailplic"i or munsorized-geent
Of5ing T�pp� Depth Casing Depth
Static Level Vield
Grow Date
Niust Conform Distances, SITF SKETCH-Na Scale
`I A 110itfild'St2tO-Codes,
llu%l Common E-Xamples Arc;
L WaWr Tight SewerUue,_.., so,
2. Ground Absorption
Sewage S"Imt............. too,
.t. Railding l uundatious.._....__.
PUM
PINH '2i�!
'I his permit hoes not ltliev,
lift!wdlAeptir vownwor
from complying oitiz sit
Galion County amt/orixorm
AV rye t t"A
Rctulntiuns and Ordinances. 5Zd
WATFR SUPPix rwok,%IATIO.N-
0 ivell location,in"Tallation and pralcrtion must v
file rvailan.Caunl. meet state and local Vegulatintiv,and must br in,,pectt.-d end appirm-M by represcritat-Wo at
'j-Hekith Department hf-Lful-e 21jy purfinu of the lbstallati-in is put Into use
0 The silivig orthe well jsy tile Ijealill Departineal staff is to pravidg Iff'OtCOJOIS FrOm.KNOWN liowale jo4rces.irronjamination. �o quantiry LWdAlr quality of water it.guaraortied 21 aliv site by thr 11calth Department,
Illen to I Beall If Sert ion 17 04853_5.00)for,hn"eyl ologica I Bull mpr'20 c waterlampt
T-A&A.
DATI-,.'JS.St)Fj) FJ4 S
DATE itFt.l,HEAD 1N1'_Pk(-Tl()_N;(,'gNtpl E
I'M VAID 5 3N4 r)ATT.
DATE,S4A1 21( Ift
X.N.J.917-7F.P ATT,�QF C-TFR
0 SN'47M.RFSVIIIN
Original white: Hezith I)epamu,",
Pink: Int-pection J)epr. Ycllmv: 1%prdleanl Cot)