GW1--04689_Well Construction - GW1_20230721

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1
1.Well Contractor Information:
Kyle C. Shaw
14.WATER ZONES •
Well Contractor Name FROM TO DESCRIPTION
4521-A 5S Cft 555 ft co neM .
NC Well Contractor Certification Number
IS.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Advanced Well Drilling, LLC FROM TO DIAMETERTHICKNESS I MATERIAL
Company Name a-
ft . 1 a, ft 6 in• Heavy PVC
13 0 3 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction on Permit#: FROM TO DIAMETER I THICICTF-SS MATERIAL
List all applicable hell construction permits(i.e.UIC Count:State,Variance.etc) ft. ff. in.
3.Well Use(check welluse): ft ft. in.
Water Supply Well: 17.SCREEN
❑AEC1Ctllinral FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑_Municipat/Public ft. ft. is
I
❑Gootitetmal(Heating/Cooling Supply) 8Residential Water Supply(single)
ft ft. in.
❑Industrial/Cottlntercial ❑Residential Water Supply(shared) I
❑kTieaiion is.GROUT
❑wells>100.000 GPD FROM TO MATERIAL E\IPLACE\IEST METHOD Si.AMOUNT Non-Water Supply Well:
\foaitotitlg o ft 10 rt Bentonite Poured
❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ft. ft. -
❑Ground\\ater Remediation
I7Aquifer Storage and Recova 19.SAND/GRAVELPACK(if applicable)
Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMEYTMET1HOD
❑Aquifer Test 1 ❑Stornmater Drainage ft. it.
❑Experimental Technology ❑Subsidence Control D. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG(attach-additional sheets ifnecessar•): -- ' -
❑G;otltermal(Heating:/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION.(color.]rardness soWtnektcpe• xain size ate) _
a " �D ft %i - /({o
4.Date Well(s)Completed: r'/`?.,� Well ID= yL9 ft ,K� ft: J } i;l
•
5a.Well Location:i S ft -� 1_ft. "1(1 ck f��� Co(,k
l-6;t/1 CletTlrl� �-16 e�► '�j �o�.fL ClS� ft �t4tcaC`�i�f\6` � r,�
Facility/Owner Name Facility ID=(if applicable) ft. ft �J
1s1 3}• revs; E I it ft R ECERIE
Physical Address,City,and Zip ft -ft.
_ c�. 21.REALARKS JUJL.6) "1- %II%1
r
County Parcel Identification No.(PEN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: lnbofst^.a��ft r rr ar>r�Uni
(if well field,one lat/long is sufficient) `1'�J '
.3 c..60 --3,4, N • C)..-9q0 5'. W __ ;24.W.--22.Ceertific/cation: • ! ; -
S-U-2.3 6.Is(nre)the well(s): ]¢Permanent or ❑Temporar Signan$e of Certified Well Contractor Date
•
Brsigning thisfornt,I hereby cern),than the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or iNo LS-1\C1C 02C.0100 or 15.4 NC4C 02C.0200 Well Commotion Standards and that a copy
!phis this is a repair.fill out krtoun well constriction information and erp ojn the nature of the of this record has been provided to the sell omen
repair under 21 remarks section or-on the back of thisfornt
23.Site diagramor additional well details:
8.For Geoprobe/DPT or Closed-Loop Geotherna l Wells having the same You may use the back of this page to provide additional netl construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of ills (add'See Over'in Remarks Box).Y ou may also attach additional pages if necessary.
drilled:
24.SUBNUTTAL INSTRUCTIONS
9.Total well depth below land surface: 6 S (ft.
For multiple wells list oll depths if different(trample-3(11200'and 2•¢I00� } Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ( 24a. For All Wells: Original form to Division of Water Resources (DWR),Ifnwterleve]is above casing.use'= ' (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR.Underground Injection Control(TUC)
•
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well conshvtction.method: 4,r("��r}-`��,I
(Le auger,rotary cable,direct push,etc.) 24r For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county\\here installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR.CCPCUA
13a.Yield(gpm) !t'1 ]Method of test: Air Permit Program.1611 MSC,Raleigh NC 27699-1611
Db.Disinfection type: TH Amount: I l 1,S
--C''= North Carolina Department ofEnvironmental Quality Division of Water Resources

. (IW
ICH® Environmental Health Division INSPECTIONS: 704-664-3703 Statesville Office:[phone]x3456-Mootesville Office:[phone]
PRIVATE DRINKING WATER WELL PERMIT# 3 IF 3c3 PIN# 4 34 - 8(v - zt 3 01 T e of Permit circle one : ens Re air Abandonment
APPLICANT/OWNER N ADDRESS: 3 1M I I(1t soy) P, cu� C PIosgPS PHONE: 14'U�{'3(�'01,25(
DIRECTIONS TO SITE: VJ 1� F -'l`-) ��1 - )( a �?YeG�rvi 5 2 f' E's -4 • •
SITE ADDRESS: I5 LS-1'YZ°Gta1Side l 31% 'S 1)-r: MOOre_51/I I I- L 21 I%UBDIVISION: &"VPGtwnGii1 5I 2 S SECTIO /LOT: (
\ Initial Site Sketch/ ' ,,
Total
/
GROUTINGDepth RESULTS
1
\
Depth of Casing
1 /
/ Yield
/ inei Gpposi Notes:
—
e_ � / / 5� S f � 11 U�
1 . f x1co, / S1d.e NCI S� fit'
/ 'i -3.
--< ', :5-:./V:;-. /el •
O
o / / ��pOSCGQ \N . • \
1 \ A s/ l6LLS2 .—, ,
..
[ ,s,
// i. tr) 1
I ,
/ ,
I a* 75b I
'5 LD{- i' I Well GPS Latitude:
r216V1b01%s 7 Longitude:
-15-). Na7 s
PERMIT CONDITIONS/COMMENTS: 211/W a l NGAG (9.0, 1rJP,U fruI2s � s���-I- ' rail & se-f- ' 2-o' Ca 5/145, I/4A,L'I4.in ss i 4 r,n-
`''.,S¢ytuaurrs, Knr .%vita ,p_.i-c6iA�?P , ::vjll rl� v [.( C(xc\
WELL PERMIT ISSUED BY: to ., .i,_.d.A . DATE: 3012'a-- (Permit is valid for 5 years from date issued.This permit may be revoked if it is determined there has been
a material change in any fact or circumstance upon which the perm lis issued. Actions of the employees of the Iredell County Health Department shall in no way be taken as a guarantee that this well will produce water
of any particular quantity or quality or for any amount of time. Employees of the Iredell County Health Department assume no liability for any damages,either direct or consequential which may be caused by this well.)
Well Contractor: CONTRACTOR CERT#: GROUT INSPECTION BY: DATE:
OR CERTIFICATION OF GROUT NOT WITNESSED BY DEPT: DATE: WELL HEAD INSPECTION BY: DATE:
WELL HEAD INSPECTION(check when completed): GROUT TO GROUND SURFACE 0 WELL CONTRACTOR ID PLATE 0 , PUMP INSTALLER ID PLATE 0 SAMPLE PORT 0
I ACCESS PORT/VENT 0 WELL SEAL 0 WELL HEAD 12 INCHES/PITLESS ADAPTOR 8 INCHES ABOVE GRADE 0
CERTIFICATE OF COMPLETION BY: DATE: WATER SAMPLES BY: DATE:
'Attachments:Form GW-la(required except for abandonment)❑ Form GW-30 0 Water Sample Results 0 Plat 0 i.). ''1*V, r, ` ,.{ AVM lN ,pe ° ___tf