GW1--04690_Well Construction - GW1_20230721

WELL CONSTRUCTION RECORD GW.1
For Internal use only:
1.Well Contractor Information:
•Kyle C. Shaw -
14.WATER ZONES
Well Contractor Nate
TO DESCRIPTION
4521-A
ft.NC Well Contractor Certification Number ft 'r
is.0UTERCA�G(formniti-cased wells)ORLINER(ifapplicable) -
Advanced Well Drilling, LLC
FROM TO DIAMETER THICKNESS I MATERIAL
Company Name ft- `--7 6 in.
' -(� f) 16:INNER CASING OR TUBING(geothermal closed-loop.) PVC
2.Well Construction Permit#• ) . ,
S �� >legal ro
List all applicable ttell construction permits(ie.G7C County;State.Variance:etc) ft DIAMETER
�cRNESS MATERIALin.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN - .
C14giicuitttral FROM TO DIAMETER SLOT SIZE THICIZIESS MATERL-1L
❑Municipal/Public ft. ft. )a
❑Geothermal(Heating/Cooling Supply) eiResidential Water Supply(single)
OInduslrial/Commercial OR ft in.
�identia111rater Supply(shat�d)
❑lineation I&GROUT
❑Wells>100,000 GPD FROM TO MATERIAL E}IPLACEAIEVrItEIHOD.0AMOUNT Oltritiation Supply Well:
O�tonitoting 0 ft. 0 f• Bentonite I Poured
Injection Well: ORecoven IL
it
O Aquifer Recharge ❑Grounds}star Remediation ft
quiferStorrtge and Recovery ❑SalinitpBonier 19.SAND/GRAVEL PACK(ifapplicable) = -
QtlOAquifer Test , FROM TO I MATERIAL E\IPL4CEilf�-'7',IIETHOD
lm
❑Stonater Drainage ft ft.
OEiperimental Technology ❑Subsidence Control ft, n
I
❑Gaothetmal(Closed Loop) OTmcer
❑Geothermal(HeatingiCooling Return) ❑Other(e plain underg21 Remarks) 0 Di2II,LLtiGLOG(attach addltionalsheets ifnecessary) .; =,
FROM TO DESCRIPTIONI (color.hardness soli/rocktype pain size etc)
=I.Date Wells)Completed: �i` -h C) ft. 0 •
r` 4 r—`1 (.I,,,�
- r;�Well IDS K D ft_ 6,5 ft a,11-, �,-k
5a.Well Location: , f6 73 It
o,�'tbt'� n• •ter", fL -7 As Clan r1 g u �,i;' rz( p 1.e A r
Facility/Owner Name Facility ID-4(if applicable)
fL ft i t d..-. W
c"('lSrrlf > s1,n es — j��,o��ti�lf� �t IL. it.
'� JUL 2 1 Z0Z3
PhysicalAddress.City,and Zip - ft ft.
'-if 21.RE14L�RKS h-i' ar.._'i•'rt Ptrnrsistie ,.7 Ut.%
County f}r�p�r`; +
Parcel Identification No.(PD)
Sb.Latitude and Iongitude in derees/minutes/seconds or decirml degrees:
(Swell field,one lat/long is sufficient)
22.Certification:
j u ` N D. q Z w /4„,/;(4 - r,_.
6.Is(nic)the well(s): l Perntanent or ❑Temporar 2,3
stenatt&ofCertified Well Contractor _(,_,)3,
- Daze
7.Is this a repair to an existing well: pYeS or Bvsigning thisfornn.Thereby cert fythar the well(s)war(were)constructed in accordance with
La 10 Li.?NC4C 02C.0100 or 15.4 t\C4C 02C.0200 Well Construction Standards and that a copy
(This is a repair,fill out known well construction information,and explain the nature of the of thus record has been provided to the well owner.
repair tutder=21 remarks section or one the back ofrilis farts.
23.Site diagram or additional well details:
&.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 NUMBER-of}}ells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
74.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: —7
For multiple wells list all depths if different(cranrple-3(g}300 i nd 2tal0o� (R.) Submit this GW-1 within 30 days of well completion per the following:
10.Static water Ieyel below top of a; 1 ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casinguse._• �' /6�(?
( Information Processing Unit,16I7 MSC,Raleigh,NC27699-161i
11.Borehole diameter: 6 fm) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(TUC)
Progra_ m,1636MSC,Raleigh,NC 27699-1636
12.Well construction method: ;,r-- Pn-1-or�./
(i.e.auger,rotary,cable,d A irect push,etc.) ( 24c.For Water Supply and Open-Loop Geothermal Return Wells;Copy to the
• county environmental health department of the county there installed
FOR WATER SUPPLY WELLS ONLY:
7 13a. 24d.For Water Wells producing over 100,000 GPD:Copy to DWR CCPCUA
'Yield(gpm) c� Method of test: Air Permit Program.1611\ISC,Raleigh,NC 27699-1611
13b Disinfection type: HTH Amount: ,/
Pc-iCW1 North Carolina Department ofEnvironmental Quality-Division of
Water
Resources ._ -

\.)
MHO - ErivIronmentail He e10 MN!'ellen Statesville Office [phone] Mooresville Office(704)660-3625 PE,moi JAI# 3 (7) it 9
PRIVATEDRIANTAN WA YER WELL PERI1/111 PR,#Ltep 39. — 71 —9 t€R6 Type of er 1 r . c e a e, ter *.epair Abandonment
APPLICANT/OWNER NA 1E ump,._,„ 0, .-111, 4,4, ..._..., ADDRESS: 4.. LA"I- ';' --' a ad 1(' -' PHONE:'-'7 '-/3&b aQ 5)
DIRECTIONS TO SITE: ..., -4- ‘ 4.i k - 1_,i —- ..... *--- .1.1,,,,, , ,g I r ,1_,9_, - : ;„ ".„.... '
-.Aft Al Al
SITE ADDRESS: SUBDIVISION: - -.1--v-i-,,.e.1 ..c-';'rl e- -".7-gc4e;-4-e_L..' SECTION/LOT: L.„6-j-
Initial Site Sketch
. Se-ate, h CIO
GROUTING RESULTS
1
.
/ Total Depth
Depth of Casing
Yield - ---
i_n
— -
Notes:*A.)-0+----- .11-k-fr
_ _ _ _
t ... PL._
/
1
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s 7
Q ' eti
1,0
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-'44'is'
0 1 Lb+
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1
brcl; ,giol 1 3 9 (et
eir
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lb ' ...--
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P
Well GPS L - •2-1.3 44 5.=teP q --iiituie,
.
Longitude:
, 1
rircoNoinomsjcoiniEn • , k)c_A-e_. a C., ru ( cf> e_ia,.,7Cr- -0- LAn -'4 e ' '
WELL PERMIT ISSUED BY: -, - -,----4 DATE:,,... (Permit is valid for 5 years from date issued,This permit may be revoked if it is determined there has be'en
a material change in any fa ct or circ stance upon which the permit is issued. Actions of thee ill oyees of the lredell 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 trade County Health Department assume no liability for any damages,either direct or consequential%vhich may be caused Iv this well.)
Well Contractor: CONTRACTOR CERT#: GROUT INSPECtION BY:
DATE:
,
OR CERTIFICATION OF GROUT NOT WITNESSED BY DEPT: DATE: WELL HEAD IIRECTIONpt .._ .__ DATE: .•._...
WELL HEAD INSPECTION(check when completed): GROUTTO GROUND SURFACE 0 WELL CONTRACTOR ID PWi:.0 PUMP INSTALLER ID PLATE 0 SAMPLE PORT 0
ACCESS PORT/VENT 0 WELL SEAL 0 ILL HEAD 12 INCHES/PITLESS ADAPTOR 8 INCHES ABOVE GRADE 0
CERTIFICATE OF COMPLETION BY: ' DATE: WATER SAM 4S BY: DATE:
,.._,
liecttacirrkents:Fern,Gi/V-13(muired excaaj"or al24Lxkinrrten01-1 Form GW-30 0 Water Sample Results 0 Plat 0 "= ' "
...