GW1-2022-10382_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORD(GW-I) For Inwivil Use only:
I.NVetl Conti-actor Wormation:
Kyle C. Shaw 14.WATER ZONfiS
Well Contractor tiame FROM TO DESCRIPTION 1
4521-A ft. 5
\C Welle11 Contractor Ce tificati Iq
on Lumber 15.OUTER CASING for tnWU-o d wells OR LINER(if up livable
Advanced Well Drilling, LLC FROMM To DIA.\IETElt TH—UlT Ess NUTERLIXL
Company Name ft. —7� IL6 in. Heavy PVC
J�� 16.MRSER CASING OR TUBING(geothermal closed-lop
2.11'el!Construction Perinit M e FROM TO Dt AWrER Tutcl.-vsss NIATERtu
au;j
List all applicable Well constriction permits(i.e.t;7C,County,State.Parionce.etc.J f. 1°
3.11'ell Use(check well use): ft. %
Water Supply\Fell: 17.SCREEN
FRO][ TO DFA,\tEtER SLOT SIZE I THiCIu�ESS MATERIAL
0-Agricultural ❑\Iunicipal,Public ft. m In.
❑Geothermal(Heating.'Cooling Supply) MResidential R%ater Supply(single) fL f. is
❑Industrial/Commercial ❑Residential'Water Supply(shared) Ig.GROUT
Mitigation OW-as FROM TO DLITERIAL MPLACEMEN-I' tETHOD&AMOD17
i\on-NI'ater Supply IVell: kL ft Bentonite Poured
❑tlMonitoring ❑Recovers• ft. M
Nection«'ell:
0-Aquifer Recharge ❑Ground-mater Remediation ft. ft
❑Aquifer Storage and Recovers ❑Salinih 1%SA,1�/GRAVEL PACK tf alinable Barrier FROM TO MATERIAL I EMPLACE\rErT METHOD
❑Aquifer Test ❑Stornmater Drainaea ft. ft.
❑Experimental Technology ❑Subsidence Control rL R
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary
FRO\I TO DESCUPTION(color,hardness,soWrock type,grain size,etc)
❑Geothermal(Heatins,'Coolina Return) ❑Odter(e. lain under=21 Remarks)
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4.Date«'ell(s)Completed:) ctl.1 Nell ID,# R "7 fL eta oa4 rnt IC
Sa ►fell Location: _V_
// h�h (( h rL
Facilitylon-nerName Facility IIID=(ifapplicable) ft. ft. EIVE r
rL rL
Lac_ (a.tJ:nc� . -A,�iJr".cC"i..r� 1�=+ 1
Physical Address,Citv,and Zip fL ft. 'Nov Ie.
2022
L',YX' a I1 1'1 'I.REIL�RICS
County Parcel Identification No.(PL\1
r .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if%vell field,one lat/long is sufficient i 22.Certification:
6.Is(are)the well(s)" t-Permanent or CTempornn- Mnar&c ofCerti ied Well Contractor Date
Bt'sigwng atis form 1 herebt•cen16•that the a en(s)W us(Here)constructed in accordance With
7.Is this a repair to an easdnQ well: C Yes or ft.No 15.,\'C,C 02C.0100 or IS,MC4C 02C.02 00 We Construction Standards and that a coin,
4012ir is a repair,fill out known Well coutnretion ityormation a»d explain the nature ofthe of this record has been provided to the[cell aivtea
mpair tinder=21 refit arks section or on the hack of this form
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal\Veils havi i!the same You may use the back of this page to provide additional well construction info
construction.only 1 GVV 1 is needed. Indicate TOTAL\UMBER of-wells (add'See Over in Remarks BaLx).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J J'�> (ft.)For Submit this GAi'-1 within 30 days of well completion per the following:multiple Wells list all depths ifdioirent(example-33(d200'mid 2 g 100')
10.Static water level below top of casing: Z' o (ft) 24a. For All «'ells: Original form to Division of Water Resources (DRR).
Ifi+uter level is above casing.use '=' Information Processing Unit.1617 RISC.Raleigh.\C 27699-1617
11.Borehole diameter: 6 (�) 24b.For Infection Wells: Copy to D1kR.Underground Injection Control (JUC)
Proerum, 1636\ISC.Raleigh,\C 27699-1636
12.Nell construction method: Ai c Qo b ` 2 lr.For Water su Ic and O Loo Geothermal Return Wells:Co to the
(Lc.auger,rotary,cable,direr push etc.) counts•environmental health de:partfinent o e county uiiere installed P.
FOR RATER SL PPLY WELLS ONLY: 24d.For NA titer►►'ells roducinLy over 100 000 GPD:Copy to DUitR CCPCUA
13a.Yield(gpm) M Method of test: Air Permit Prneram, 1 11\ ef_ 27 -1 1
13b.Disinfection type: HTH Amount' 1 1 LK
North Carolina Department ofEri ironmental Quality-Division of Water Resources a":.�_a. ;

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LINGOLN COUNTY HEALTH DEPARTMENT
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WELL CONSTRUCTION PERMIT
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