GW1-2023-01563_Well Construction - GW1_20230209

_WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: =
a •
1.hell Cont1•actor Information:
Kyle C. Shaw 14.WATERZONES.- i
FROM TO DESCRIPTION I
Nell Contractor Name g ft i
4521-A 3 "aa M.
ft ft
NC-lVell Contractor Certification Number 15.OUTER CASING for multi-cased plls OR LLNER'fif a licable
Advanced Well Drilling, LLC FROMTU l DLL.fEfER THICh� NUTU
ft rt 6 ?n Heavy- PVC
Company Name
16.IN1VER SLNG OR TUBING(geothermal closed-log
2.11re11 Construction Permit#:--n >:ROAS To ntanu rEu' rl tctt vFss 1rATERIAL
List all applicable ell construction permits(Ze.UM State.Mariance.eta) ft ft
w in.
ft ft liry
3.Well Use(check well use):
Water Supply\\yell: FROM I TO DLAAfETER SLOT SIZE THICh1iESS I LITERLAL
❑Agricultural ❑R4unicipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) rL in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 19.GROUT-
01niQation ❑Wells>100.000GPD FROM I To M1TERUL &1n'L.4CEMENTMETHODS%AJOUNT
Non-1A'ater Supply Well: 0 ft 0 ft Bentonite Poured
❑Monitoring ❑Recovery ft ft
Injection Ni'ell: n, ft
❑Aquifer Recharge ❑Groundwater Remediation
19.S4ND/GRAti7ELPACK ifa licoble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL E\IPLACE\IEr'TMETHOD
❑Aquifer Test ❑Stonnivater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control M ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLLtiG LOG attach additional sheets if necessary
FROM TO DESCRIPTION(color,hardness soWrocktype.gain size,etc)
❑Geothermal(HeatinJCoolinlg Return) ❑Ot►ter(explain under 721 Remarks) � ft 0
4.Date Well(s)Completed: 1 �" Well II!f -7 Z-) ft
Sa \fell Location: 9aus
1 1 �t ft ft
Facility/Owner Name Facility 1134(if applicable) ft
�r�x 1�� ft. n I _
Physical Address,City,and Zip
C°6'_ RI:S
dX-id 21:REDIA
fd •..r t�,d
Countv Parcel Identification No.(MI) �tre Qf r�1 v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s): MPermanent or ❑Temporary Siena a of Certified lVell Contractor Date
Bvsigning thisforni,I hereby certff}+11mt the it-ell(s)was(were)constructed in accordance with
7.Is this a repair to an eastitr'well ❑Yes Or LeNo. 1.id IUC4C 02C.0100 or 15.4 ATCAC 02C.0200 Ilrell Constniction Standards and that a cop,
If this is a repair,fill out known it-all cotutniction information and explain the nahire of the of flits record has been provided to the well owner.
repair under721 remark section or on the back oftldS fornn
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to'provide additional well construction info
construction,only 1 GW 1 is needed. Indicate TOTAL NTAIBER of wells (add'See Over'in Remarks Box).\ou may also attach additional pages if necessary.
drilled:• 24.SUBNIITT L INSTRUCTIONS
9.Total well depth below land surface: 365 (f t) Submit this G11'-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiifferent(example-3a?00'and 3}00')
of casing: 24a. For All Wells: Original fo I ito Division of Water Resources (DWR),
10.Static Hater level below top �: t�0 A) Information Processing Unit.1617?MSC;Raleigh NC27699-1617
Ifiruterlevel is abave casing,use' - - •:
il.Borehole diameter 6 (m) 24b.For Injecton Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636MSC,Raleieit..NC27699-1636
12.Well construction method: t c' 241ES=4 24c.For 11'ater Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR\PATER SUPPLY WELLS ONLY: 24d.For\rater Wells produSLng over 100,000 GPD:Copy to DWR,CCPCUA
rryy Air PermitProgram.1611NISC,Ralefgh,IC27699-1611
13a.Yield(gpm) dt�� 1lethod of test:
t� I
13b.Disinfection type: HTH Amount: �4]y
i
;:o7,GIV-1 \orth Carolina Department oflindtrormmental Quality-Division of Water Resource f Revised 6-5 201 S

ICHD-Environmental•Health Division Statesvliteofoce [phone] X3456 MooresuHle0i8ce 04)860.3625 P MIT#AP 3 z301.4-S
PRIVATE DR/NK/NGWAT©?WELLPERRY PIN# 2 -- ( ) Repair Abandonment
'�° ==� -r�►2 Type of Permit circle one):
APPLICANT/OWNER NAME:r-mnijafifiir►tln i'ytoSieSidov,i-rnlul ADDRESS: -+�£3 r2e)a ���aa�o< ;i;yJ2Dll'7 PHONE:�b4-�to�-2Z�1
DIRECTIONS TO SITE:-1�3 Y-FI1 f7eil nI- nt� G e y ,1,: t - `7"Y4-1'1 f- pl Yl o.C_ , . Go T b r�
SITE ADDRESS: . I I i r7LI,)-I- 'PtyU( �Y i y o, ti10DAE5Vlct,ti,M,G, ZQ12 SUBDIVISION:WoCd l on-F SECTION/LOT: —
I IN-�'gfT Initial Site Sketch
ROUTING RESULTS
pffP y Total Depth
Zia' Depth of Casing
Yield
lS' , •
Notes:
A 2EA
,ra
f3o s T�
S3, $u ({I 5EP
PQ0Po56D
RPCEP DZ'
Tvfr4 P°0✓ s�
P,"ri'-
DKto6
32'
PeoPDS'ED O� �A� 17' hUEli/oCfFl Z3 i7'
b ' 3`,
--- — - - -- --- - ---- L
- - - -------- ---- --- --
PERMIT CONDITIONS/COMMENTS: scow ALL- None Zc w£c[ 2LILe5 G-Rov; nnrn�tivtt/,v� nF 2o-fT
WELL PERMIT ISSUED.BY: B G, �- DATE: Z-Z-3-Zo2 2- (Permit Is valid for 5 years from date issued.This permit may be revoked if it is determined there has been
a material change. apyfactorclrcumstanca upon which the permit is issued. Actions of the employees of the Iredell County Health Department shall in noway betaken as a guarantee that this well will produce water
of anypiitticu larquantityorqualityorforanyamountoftime. Employees of thelredeilCountyHealthDepartmentassumenoliabilityforanydamages,eitherdirectorconsequentialwhichmaybecausedbythiswell.)
Well"Contractor CONTRACTOR CERT M • - GROUT INSPECTION BY: DATE:
OR CERTIFICATION OF GROUT NOTWITNESSED BY DEPT: DATE: WELL HEAD INSPECTION BY: DATE:
WELL HEAD INSPECTION(check when completed): GROUT TO GROUND SURFACE❑ WELL CONTRACTOR ID PLATE❑ PUMP INSTALLER ID PLATE❑ SAMPLE PORT❑
ACCESS PORT/VENT❑ WELL SEAL❑ WELL HEAD 12 INCHES/PITLESS ADAPTOR 8 INCHES ABOVE GRADE❑
CERTIFICATE OF COMPLETION BY: DATE: WATER SAMPL_ES BY: DATE:
P
Attachments:Fonn GW-1a(required except for abandonment)❑ Form GW-30❑ Water Sample Results❑ Plat❑ :.w.; r,.
p .7# 4 a I to a #u(a graut..ar ttl itt#Errttns E ian'