GW1-2022-09624_Well Construction - GW1_20221021

SELL CONSTRUCTION RECORD(GW 1) For Intemal Use Only:
I.Well Contractor Information:
Kyle C. Shaw 14..«WATER r
Well Contractor Name
FROM TO DESCRIPTION
4521-A )t6 n IT'S. ft '3 1 '`i
hC Well Contractor Certification'-Number
la OUTER CAS fI\G(tor mtilti ca ed tselis OR LIFTER(ire licible)
Advanced Well Drilling, LLC FROM TO MWErER THICIuYESS \L4TERUL
fn .? ft 1 6 Heavy I PVC
Company Mamc
16.]INNER CAMGORTi7$ING(geothermal closed-loop)
2.1,'ell Construction Permit# _ FROM I TO DLL,MTER TEIC;CQM I MATERL L
List all applicable sell construction perntfts(Le.o7C Cottttnt state.r'arra»ce.ctc.) fit ft in.
3.Well Use(check well use): ft ft in.
Water Supply lVell: 17.SCREEN
FROM TO DIAMETER SLOTSME 1 THICIu\ESS \LaTERL-1L
❑Agricultural ❑\Municipal/Public ft ft
❑Geothermal(Heating/Cooling Supply) MRasidential Water Supply(single) ft fL
❑hidustrial/Conuuercial ❑Residential Water Supply(shared) 19.GROUT
❑h-rigation ❑Wells>100.000 GPD FROM To NUTERUL E,\IPLaCEtiL1TMETHODS L\IOL�T
Non-Water Supply Nell: tt n- Bentonfte Poured
❑\Monitoring ❑Recover= tt ft.
Injection Nell: ft ft.
[]Aquifer Recharge ❑Groundt\ater Rzmediation
` 19.54.\D/GRa4'ELPACK(ifa livable)
❑Aquifer Storage and Recovery ❑SalilutyBarrier FROM TO I EMPIACEMMT METHOD
❑=Aquifer Test- ❑Stommater Drainage m ft
❑Experimenial Technology ❑Subsidence Control ft. I ft
❑Geothernial(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color•hardness.sollfroek type.main stag etc)
t7Geotltermal(HaatinglCooling Return)�}y ❑Outer(a�plain under`21 Rnnati:s) < it 16at
4.Date Well(s)Completed: Well ID9 ZJ rt �� ft s !y 'I
5a ti1'ell Location: Cn''J rt rt -9• F€ -
FacilitylOsvnerNlame FacilitvME(if applicable) ft. ft
Physical address,City,and Zip
(t ft 4 - v
^f� t 21.RE-AL-IRKS
County Parcel Identification N.m.(PIN)
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
fi�C7frYi7itcl f Qf-'
(iftee ll field,one ladlong is sufficient) 22.Certification'
9. CV
// _
� � �� f�
6.Is(are)tine ttell(s):'C,Permanent or GTemporary Signawk of Certified I' ell Contractor Date
Bt•sigtdng th(s forng I herebr ceri ffi that the trell(s)it-as(trere)constntcted in accordance ulth
7.Is this a repair to an emsting well: ❑1-es or 8.o 151-t VC.IC 02C.0100 or 15.2 XCAC 02C.0200 11'el1 Cotutnection standards dnd that a coal
ONO is a repair.fill oat/710s71 Ivell cwtsrnrction h1fornmtion and explain the nature ofthe of this record has•been prmided to the is-ell omiar.
repair under=21 renro;-L section or on the back ofthis fora 23,Sife diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geotherr al Nells having file saute You may use the back of this page to provide additional well construction info
construction,only 1 GRr 1 is needed. Indicate TOTAL.N LT\•1BER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL L\STRUCTIONS
9.'Fotal well depth below land surface: �� (ft.) Submit this GAl'-1 within 30 days of well completion per the following.For multiple tsells list all deptlu rj d erenr(example-3L 00'and-lad 00')
10.Static water level below top of casing: (ft) 24a. For All )Fells: Original form to Division of Water Resources (DN[R),
If ureter level is above casing,use"="If Processing Unit,1617\MSC,Raleigh,\C 27699-1617
11.Borehole diameter' 6 ��) 24b.For Injection Wells-. Copy to D)NR Underground Injection Control(WIC)Program,1636-NlSC,Raleigh,NC 27699-1636
i
12.Well construction method:-Ac-ea, 24c.For Water SunDly and Open-Loon Geothermal Return li'ells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county=environmental health department of The county where installed
i
FOR R'4,TLR SL1TPLI n TLLS 0<Zl': 24d.For Water«°ells producilLQ over 100,000 GPD:Copy to MT-CCPCL+�
13a.Yield m r � Air Permit Program,1611\1SC,Meigl4\'C 27699-1611
�� ) _Method of test:
13b.Disinfection type: HTH mount:� 11s M
if-1 North Carolina Department of Environmental Quality-Division of Water Resources Revsea 5-3(sl S

ICI!i D-Environmental Health Division 5taRM1 i110O CO [phone] x3456 MOM311111005109(704)660-3625 PECN1i1C®! #AP
PRINAZE RIMING WRIER WELL PERR IT PIN#`� __ e Of Permit(circle one),.. NWD
Rapa�B".. e�itd��B��T3�E(�f�
APPLICANT/OWNER NAME: '1 I/tC ADDRESS:m� PHONE:.'
DIRECTIONSTO SITE: PSG L &alt`t W&A bAbre6Y o t:�� /n w
SITEADDRESS: J cs1M� iUifCs�n I1C'i IvG 81( SUBDIVISIQN: • SECTION/LOT: --
Initial Site Sketch r'1443TM r47
oposed kn`t' ROUTING RESULTS
Total Depth
C
(wrap. l Depth of Casing
a
DUSQ, � Yield
Pry Notes:
P064
Jaw Ile-
I�� El bdr &A QO ,41.XK1 too° a vas
PERMIT CONDITIONS/COMMENTS: Wbwall N rua 2D, - 'ti r2,gl
Z 1
WELL PERMIT IS U ED BY: I DATE: (Permit is valid for 5 years from date issued:Thispeimit maybe revoked if it is determined there has been,
a material change in any factor&rcumstance upon'which the permit is issued.Actions of the employees of the IredelI County Health Departmentshall:in noway betal(en as a guarantee that this weli'wiil produce water
of any particular quantity or quality or for any amoun6f time. Employees of thelredellCountyHealthDepartmentassumenoliabilityforanydamages,eitherdirectorconsequentialwhichmaybecausedbythiswelL}
Well Contractor: CONTRACTOR CERT#: GROUT INSPECTION BY: DATE:
OR CERTIFICATION OF GROUT NOTWITNESSED BY DEPT: DATE:. WELL HEAT}INSPECT ION BY: DATE:
WELL HEAD INSPECTION(check when completed): GROUT TO GROUND SURFACE❑ WELL CONTRACTOR ID PLATE❑ PUMP INSTALLER ID PLATE❑ SAJiPLEPORT❑
ACCESS PORT/VENT❑ WELL SEAL 0 WELL HEAD 12 INCHES/PITLESS ADAPTOR 8 INCHES ABODE GRADE O
CERTIFICATE OF COMPLETION BY: ' DATE: WATER SAMPLES BY: . _ _DATE:
777777
Attachments:.Form GW-1a required except for abandonment}❑ Form GVV-30❑ 'Water Sample Results Plat❑ I b � �'�'((���^ ply' t I $'<yy 1A xr ¢t?vr�wt G( p a.;a{,.- "tJ4^ [1 '6:;5 r VbSl.,�a i11Y LC16&..1•ti#.✓•71 6a le yr-.h^: