GW1-2022-10381_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
il
1.n'ell Contractor Information:
Kyle C. Shaw 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4521-A co IL `' tL rn
NC Well Controotor Cortilication Vumber
Advanced Well Drilling, LLC 15.OL-I•ERCASIING for multi-t-rsedtirells ORL11tER(Ira llcable
FROM TO DL4\fEIER TmCI.�ESS �LATERL-%L
Comxn} Sam-.
it- 4 n 6 in. Heavy PVC
�(]� 1^�-� ^� 16.ININER CASING OR TUBING(geothermal closed-loop)
2.1Yell Construction Permit#: T7 U, � V 29 cam„ FROM To DwiETER TMCI,•%Tss MATERLt.
List all applicable urrll construction perntits(ie.VX County:Stare.lariance.ere:) IL ft. in.
3.Well Use(check well use): rc ft in.
Water Supply 1Vell: 17.SCREEN
FROM TO DIAMIFTER SLOT SIZE THICKNESS I \IATERL-kL
❑Agricultural ❑MunicipaliPublic n is
❑Geothermal(Heating-'Cooling Supply) IdResidentiai lvk' n
ater Supply(single) IL tt ;n.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑kTigation ❑Wells>100.000 GPD FROM TO MATERLAL E,\IPLACENrE\T AfETHOD C-.LIIOI:.NT
Non-Water Supply 1Ve11: ftQ�Q it, Bentonfte Poured
OMonitoring ❑Recovery It. It.
Injection Well:
❑.Aquifer Recharge ❑Groundx\ater Remediation rt ft
19.S.AIND/GlUVELPACI; fa licable
❑Aquifer Storage and Recover}- ❑Salinity Barrier I FROM To JL►TMUAL E\rPL4CE\107 METHOD
❑Aquifer Test ❑Stommtxater Drainage ft. IL
❑Experimental Technology ❑Subsidence Control ft. FL
❑Geothemial(Closed Loop) ❑Tracer 20.MLLLNG LOG(attach additional sheets If necessary)
FROM TO DESCRIPTION(color,hardness.soWroek type. in size,etc)
❑Geothermal(Heatintl;Cooling Return) ❑Other(explain under=21 Remarks)
o It. So rt. 0 t C
d.Date Well(s)Completed: � C- AV_ell ID# ft. D E#
5a.Well Location: ! 1 n. ! r. '
�or'l2 1lde�'S -4 n 1 35 rr
Facility/OnnerName Facility ID=(ifapplicable) M It.
13
Physical Address,City,an 'Zip fL it !.
L C& 21.RE1LUU3
I �
Couary Parcel Identification No.(PEN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifuell field one W/long is sufficient) 22.Certification:
C:3
6.Is(are)the\rell(s): CiPermanent or CTemporary Signar&e of Certified R°ell Contractor Date
t3rsigning thi5f0m4 I hereby cerffp[hot the trellis)was(trere)constntcted in accordance with
7.Is this a repair to an esistin g well: G Fes or L.No 13;\'CIC 02C.0100 or 1 S.•t MC1C 02C.0200 Well Constntctfon Standards and that a cam
Ifdris is a repair,fill oat blou tt s,ell cautntction h9bmtation and explain the nature ot'tlte of rids record!,is been prot4ded to the u el!otnter.
repair under=21 remark,section or on tire back gfthis form
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havilma the same You may use the back of this page to provide additional well construction info
construction,only 1 G1114 is heeded. Indicate TOT AI..N'C [BER of tveils (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
2.1.SUBMITTAL INSTRUCTIONS
9.Total well depth it lowdepths
land surface: ft.) Submit this GIV-1 within 30 days of well completion per the following:
For multiple ue/ls list all deprlu ifdi-jl'erem(cranrple-3/ia300'and 3a i00'm
10.Static water level before top of casing: pC7 (fL) 2•la. For :ill Wells: Original form to Division of R%ater Resources (MR).
If water level is abore casing.use"=' Information Processing I niL 1617\ISC.RaleiqJL\C 27699-1617
11.Borehole diameter: 6 (In.) 24b. For Injection Wells: Copy to MAIL underground Injection Control(IUC)
r� Progatn. 1636\ISC.Raleigh.NC 27699-1636
12.Well construction method: A,,C- 1-izya�-o
(ie-auger,rotary.cable,direct push,etc.) � 29c.For Water Sir Iv and Open-Loop Geothermal Return Wells:Copy-to the
county environmental health department o the county where insta led
FOR WATER SUPPLY WELLS O`ZY: 24d.For Water Wells esoducing over 100 000 GPD:Copy to DU CCPCUA
13a.Field(am)_��� Method of test: Air Permit Program. 1611. et m.m 27 R.99-1
13b.Disinfection tr e• HTH I
P • Amount: IJ4
Nonh Carolina Department ofEmironmental Quality--Division of Water Resources ge.•.5_�t<__

S
r ��� �� ��'� s ,;! +fir. .. '-4'..s......P ���� ��,a'5�,. ,�•�'+v+rS: (To4w +�
- -- - Ch r;
14rZip- 24"2
5,3
pats TINT# y FSTkTjFs
s Z)P.
his WE
UCT1 ,
11 t.
ly
v exc -
i
H0u5c'
5Q
170 '
-- --
mat `from hotme foundWon and 50'from all Paft of the septic system.
April I UMoafiner
t