GW1-2023-01552_Well Construction - GW1_20230209

WELL OONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.lVell Contractor Wormation:
Kyle C. Shaw
14.WATER ZONES
FROM TO DESCRIPTION,
Well Contractor Name �- �• 3oL5 ft
4521-A
ft ft.
NC Well Contractor Certification Number is.OUTER CASIlVG for multi-eked wells OR LAVER rf a Roble
Advanced Well Drilling, LLC FROM I TO DIA..1EM TFnCANEss AIATEML
Company Name ft ft- 6 In. Heavy PVC
'1 16.INTER CASLING OR TUBING(geothermal closed-loop)
2.Well Construction Permit M. rT�_�nLDZ L'ly a2� FROM TO DuvtErER THICKNESS I MATERLu.
List all applicable cell construction permits(Le.IJX Count':State. I'ariance.etc.') ft. ft. in.
3.Well Use(check well use): ft t It`
Water Supply Nell: 17.SCREEN
FROM TO DIAMETER SLOTSEZE THIChNI ESS MATERLaL
❑Agricultural ❑kfunicipab'Public It. ft in
❑Geothermal(Heating!Cooling Supply) MResidential Water Supply(single) ft ft. ;n
❑lndustrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
❑irri tion ❑Wells>100.000GPD FROM TO ALATERLAL EAIPL.ACEANIE4TAtETHOD&AAIOirlN*T
Non-Water Supply Well: cp ft Bentonite Poured
❑.Monitaring ❑Recover}• n. It.
Injection Nell: ft ft
❑.Aquifer Recharge ❑Groundtater Remediation
19.SAND/GRAVEL PACK da Itcable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To ALITERMI, I EAtPLACEAIFNT METHOD
❑Aquifer Test ❑Stormwatar Drainage ft it
❑Experimental Technology ❑Subsidence Control >ti ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLLNG LOG attach additional sheets if necess
❑Geothermal(Heating%Cooling Return) ❑Odmer(eV. lain under-21 Remark-L)J
FROM TO DESCRmPTIO (color,hardoeas soWroek type.grain sire,etc)
M v ft
4.Date%Vell(s)Completed:C-6 _ 7 Nell ID# L ft fL
Sa.Well Location: n fL
Pat J
,� 1 ft ft I
1VocT�.o�`,
Facility/Owner Name Facility ID=(ifapplicable) It. rL
MJ_7
Physical Address,Cin•,and Zip ft � 2 � �% ?i
` 21.RENIARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwell field,one laVlong is sufficient) 22.Certification-
wj� � - ( --
6.Is(are)the well(s): MPemmanent or GTemporan• EignanAe of Certified Nell Contractor Date
Bt•signing des forni,I hereby cerrifj•drat the trell(s)was(were)constructed in accordance ttith
7.Is this a repair to an elasting well: [Yes or f No 15.4 VC4C 02C.0100 or 15.4 NC:4C 03C.000 Wall Construction Standards and that a copy
lftltis is a repair•fill out btoum well construction it formotion and explain die nature ofdie of tlus record has been provided to the well outer
repair render 4`31 rentals section or on the back of this forne
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same I-ou may use the back of this page to provide additional well construction info
construction.only 1 Glut-1 is needed. Indicate TOTAL NLI IBER of xNells (add'Sae Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.StBVIITT_Al.LNSTRUCTIONS
9.Total well depth below laird surface: Submit this G1V-1 within 30 days of well completion per the follow
For multiple wells list all deptlis if&fferent(example-3@300-and 2@1 W0
/ 24a. For All Wells: Original form to Division of Water Resources (DWR).
If%urer level is above casing,use"="
f Static water level below top of casing: KO 00 Information Processing Unit,1617 MSC,Raleigh,ATC 27699-1617
s
6 24b.For Injection Wells: Copy to DWI.Underground Injection Control(IUC)
( )
11.Borehole diameter. Proemri 1636 LISC.Raleigh.NC 27699-1636
12.Well construction method: A;f ),+'tr c 4 24c.For Water SuRply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc-) county environmental health department of-the county where installed
FOR 1VATER SUPPLY WELLS ONLY: 24d.For Water FVells produc over 100 000 GPD:Copy to DVitR,CCPCUA
13a.Yield(gpm) (� Method of test:
Air Fermat Program,1611 M C et .N' 27699-161
13b.Disinfection type: HTH Amrtount. 16S
C-tl'-I forth Carolina Department ofEntironmental Quality-Division of Water Resources Revised 6-6-201 c

145 West Main Street- LINCOLNTON, N.C. 23092 -PHONE: [phone] - FAX: [phone]
Permit#: EHW22-04427 Parcel Id #: 23500
Owner: VAILLANCOURT ERIC A Phone:
Address: 18 RATHUM MOUNTAIN ROAD City: BARKHAMSTED State: CT Zip: 06063
Applicant: NORMAN PAUL Phone: [phone]
Address: PO BOX 2069 City: DENVER State: NC Zip: 28037
Location 1407 BREVARD PLACE RD Sub: Lot#:
WELL CONSTRUCTION PERMIT
*THIS IS NOT A SEPTIC IMPROVEMENT PERMIT OR CONSTRUCTION AUTHORIZATION*
��e CIJ+0-1�C- j S 41(1
;MIN DISTANCE BETWEEN WATER SUPPLY AND SEPTIC 1D0 (IN FEET)
CONDITIONS
April Bumgarner
AUTHORIZED bu/
AGENT'S n f�p jA DATE: 8/20/2022
SIGNATURES:
IMPROVEMENT PERMIT,AUTHORIZATION TO CONSTRUCT,AND WELL CONSTRUCTION PERMIT:EACH THE IMPROVEMENT PERMIT,AUTHORIZATION TO CONSTRUCT,AND WELL
CONSTRUCTION PERMIT ARE SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE ARE CHANGED FROM THOSE SHOWN ON THESE PERMITS. CHANGES FROM THE ABOVE
PERMITS REQUIRE ENVIRONMENTAL HEALTH APPROVAL THE INSTALLERS SHALL BE REQUIRED TO HAVE AN IMPROVEMENT PERMIT.CONSTRUCTION AUTHORIZATION(BOTH VALID FOR 60
MONTHS FROM DATE IMPROVEMENT PERMIT IS ISSUED),AND WELL PERMIT IF APPLICABLE BEFORE INSTALLING THE ABOVE SITE PLAN.