WI0300475_Well Construction Record(s) (GW-1)_20240213

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WELL CQNSTRIuc TION RECORD(GW-1) tn
PorinUea se only,
I.ivell Contractor Imennation:
Kyle C. Shaw
14.IYATFA MxEs F
Well CortlrnolorName FROM T Dl KIFTICN a
4521-A N
n n
hC OVcll Car+racoor Ca:ttle:den iVt':raber
RCA81TG er �redwe"; R raR
ORliIYEoble
Advanced Well Drilling, LLC 15.QL f[torr Tq moiuDFM KATEa1AL
Company*attte CJ r` n, 6 tn, Heavy PVC
�y ,. II CASING 0 II731NG cofhertoa]elaed4o
2.Wall ComtructlonPelTnit#: �`-� boi — G 3 rnons To DLAXIzrsa Tar rctv[sa nuxcntaz
Ur:all opp oble,pelf csor.Ftroufon permits(La,VIC.Coeur)',$fare,1`m*ujcr.eoc) T. a ft la,
3.titi'ei1 Use(check%Yell use): sc M hL
Wa4 r9uppLv Nell; 17 SCREEN
D.9gnc�uitural D 70 DIAMETER ME THICfCaF AtAT
Oibhnlioipal Rklic n. ft. in. t
DGaotitwmal(HeatingiCooligg bltpply) MfRz denttial Water Supply(single)
DbtdustriaVCotttfgerclat tt m In
Oltrsidexttial Watts Supply(sneered) tfr.GRot1T
Orni Lion Owens>ioo goo GPA lxonu ro near T MEnson a aaro F E '�
Nan-Water Supply Well: (7 R' n Benton Poured '
aMonitoring ❑Rocovrry n
Afwcuun r4
C7Agaifbr Rech�6a
n
QGrotmdnatar Rentedtatlon
13Aquifer Storage and Raao%vy DSalini Barrier to Sd?IDIGRAYFLPACK tea ltvtble
FROM to hL1TCRIAL GTFPI.4CE)tFYTHCTNOD^ t
4AquiferTast ©Stonia%werDrainage ft R ;(
OL•'.Sparirnental Tpvhnology DSubsidence Control ti it
DOeolhotraalCC1osedLoop) DTsacer to Nor, ens haddManaJ%ht neKeaa
DGeothemnal Heatin Caa]In Return COdtzt( , lain under#21 Remarks FH D93Cnmt(X colorLMroar: eu,exl
S C '
4.17ate well(s)Completedv Nell M# n i) n CSC k
53.Well Lomtion: ft 410 it S C f C:e k-
fL KS (L otr� rvt
Focilitp/4a7rerNane Faclity04(irapplicabla) Li
e& � S IL �6 t Jt',jC rt
Phy:fcal'ddram%City and zip C ; fnt F a C-
CC393ty Parcel ldentiacatl"'No,iPMN)
5b.Latitude and ImV tulle in degr•ees/rr bWeslsecands or decirnal degrees:
(if well field one W loos is sr9iciea) '
—3 z a Z_ �� 22.QrWleailon:
6 ]a(arn)the wall(s): flPcasrmtrent -611
or CTemporary Settsa ofcenirwdl tvall Canropor Data f,
7•Is tide A ropalr to an otistls>da teen: f3vsignhta,thlrforot I harfbv Cart0 thol the mull fs)mar ji wr)conrrrucYed ln,tcbord�artr nigh
ClVts or JTo Is t\C4C MC.olao or 1 SA MCtC 07C.0200 Wolf Cerwwadon Skandardt mid Naar a cope
frWs fs a r*Jwdr,fell oat k wk n snit GvMfrnabon lnfornradon aid drpfnln the norme of the, g'thu m4vrd leer been pnaidad to Ar ksdl ows ar.
t cpalr tender 021 rvnrorla section or on rho b u*oflMtfornt
23.Site dlagtnm or addltlonol well detalla: �•
t.For Geopmbc/DPT or Chmcd•Loop Geothurrn2l NVelfa having the astue You may use the back of this page to provide additional wall consbuctfo i Info
constnldM cal)'1 OW-1 is uoMed. Indicate TOTAL NUMBER of nells (add'See Ova'in Remarks Box).YOU mayalso attach additio nail pages ifneo iwra
drilled;
V.SUMNOTTAL 1NSTRUCnONS
Total even depth below land surface: r�.6 (N•) l
For nndtlplo+vl&1W all depflu(f4WIM m(tmmp&-3@200'and JrgV W) Submit this GR-1 wltIdn,30 days of well completion perthe fbHow(ng!
M Statte water letivl below top of easing: (�) 24a. For An '�Velfs Origi ml form to Division of Water Resolute: ((DW R),
4fku!rrlavcl is abmvoaaing trap"4 ItMahAtlon f^roaessing Unit,1617 MSC,Raleigh,NC 27694-)617 '
tt.Borebote dianwter. 6 (uz) 24b.For lnhecuon IyeBs:Copy to DWR,under ground InJeGitm Control(IUC)
Progtnm,1636 MSC,Raleigh.NC 27699-1636
12.Welt cWey,cable,
method. tL' 24c, or Water Su v and O -Loo GeotharnW Ito 4yr1h;Copy to the
(ie.aagat,rotlq,cable,d'aeot pw}s,eta)
etwDs)'ensronment t t eparnu:nto county emmstnil
FO71MAM UPp1.,Y,YELLS ONLY:
24d,For%Vatar WtHS over] 000 t3PDt Copy to DWR,CCPCUA
13n. >4lethed oftest: AirPerDtrt MAnUn, 1 , e _23b. type: HTH
sssatmt:
?G:n Ctlt'.E \onhC2roiina 'i Deper•tmrntofEnvbunrrontalQaafit}-Division oftVatcr}tesoancrs Rrtised3=�.'SI:?,•° �•
ti

WILL CONSTRUCTION RECORD W-1 For Internal Use only:
1.Well C-orttmctor Informatton:
Kyle C. Shaw 14. AT ER ZOMS
Well Contractor Name FROM TO Ditscrapi ON
4521-A n n
n n
NC Well Ceaunctor CutUicatim Number 1S,OUTER GAMING for multi-caud wells OR f a Noble
AdvanCed Well Drilling, LLC 5 TO DrtAt[�r>,2 T1OCICVTS4 lurinrru
Company N*arse f Hea PVC
�z--T 16.L1�N CASllCGORTIJSINC er���dosed-loa
+
z Wen CbngructIORFMInIt#: I" ��'��you To 1Tulesw� zs�rEatu
List all appfreab)e hell aotrrbucdon perm)u rf a.L"a CotoW;State,VartaRm are.•) % IL In
3.Well.Use(check-,teil use): n n la
Water Stipple wells 17.SCREEN
FROAi -1 TO DI [EER •17L eh 11MEREAL ' y
CIAgrSwltaral ElMuuicipal/Public it. n In
0Gaet(lentral(fieetinWCoolingSupply) nResidcntial)hater Supply(single) n n Ia
171ndustrialtOommorcial OResidential Water Supply(shared) te.csRotrr
❑Isri t[on C1Wells>100.000 GPD FROM To ut�tuAf, E�fP csAtrxx tRTBeaD s tovn r
Non-water Supply Well: fL n Bentonfte Poured
OMonitoring ORecovery 0• n
ection
❑ ulrtT RCchtlJ n It'aq $c ❑Clrotrudcttttcr Relttediation
14,SANDIGRAVELPACK tits tenble
13Aquifor Storage and Recovery OSalit:ltyBarrier raoa r
TatuAl, r:I�cs❑Aqui.rer Test ©Storm%%aler Drainage ttiC Subsidcnco Control ft. fu
OGomhtarnal(Closed Loop) 17Trbteer 20,DMU L NGLOGranacb additional 9beeta lfrmrea
0(30thermsl(F_ealin Olin ROOM) 001her( lain under 021 Rentari;s) I MAI T( DEICWTIOty tools.bw-dn em to k t n slu.etc
190 Ns rt n E 1 u
a.1)klte Welt(s)Cbinpleted: Well ID# 'q , n "- Jz
So.We11 Lotation: Sit ,�arl
Y n f5 n Ace, n
Faith,iDwncrNa.x Faoili0•IDO fappticable) rt ft
n m
Fhyx)oat Address.City,and Zip It n
21•PMNLARKS
County Parcel Iderrlllwtion lvo.(PIN)
Set.Latitude turd longttudo in degrees/minutes/seconds or decimal degrees: l"
(lfweil Md.one Isr:loag is suHiacatj 22.Ceth[irntlan:
IN %%F
6 Ia(nPB)the rveII(s): nPerYlmnent or GTemporart•' TsnavA ofCatiried well Contractor pate
Byrrgnlr�q rhrsfornt.11tarsb9 crmb•that thtr wnit(tJ>•zer(wtro,)avrutrnaed In acc�rrdottu with
7.Is vets o repair tonn esisttsg►sell: ❑Yes or 8 NQ JS4 A'C-dC 03C.010 or l SA rVCAC 02C.02090 27aff COAdrvdfcm Standards and that a cagy
Ifrhisisdropolr.fiilOrd rM"10lleautnraOuniVorntononmrdctp(arn&ajWtreoftltd oftW record bw been prO dedwtbaroil0Irner,
repots under#J)remarks seeteon or on fim bact'oftlda form 23.Site diagram or additional wen detwir.
8,For GeoprobelDF1'or Closed-Loop geothermal Wft[laving the said You inay use The back of dtiS page to provide additional IAVH eoMtruction info
artlstntctiOn.Only 1 OW-1 is needed. Indicate TOTAL NUMBER of%Neils (add'Sec aver'in Remarks Box1 YOU nmy aim aftach Witienal pages ifrlooessary.
drilled:
24•KMNHTTAL AYSTRUCnoONs
9.Toh►I weD depth ltet(w land sslxfaee: �� (R•) Submit this G/V-1 n4thln 30 drays of wet!cam eHon r rise(allot iirg;
Ira-mu1Np)O wells list aU rlapthr(f-dUreraw(scamp's.3tbjGb'and: pl pe
gl W?
10.Static waterlevd below top orewhig: (f1•) 24a. For All. trolls, Origirtal form to Division of Water Resources,(DURI.,
IfHtlror)eve)is abrnmv catoorg,asv"i" Information Processing Unit,1617 h9SC,RaleiWL NC 27699-1617
U.Borehole diameter: 6 (�) ?�tb For WecHon\Felts:Copy to DWR,Underground IlWeolion Control•(IUCI
�3 � Prog k 1636 MSC,Raleigh NC 27699-1636
I7.Won constructlortrretttod; / �F` JcDttxC'I,,p_ 24e,ForWater 1 and0 tar-Loo GeetherrnJ Return 3 'e1 Is:CufsytoU10,
(i,e augv rotary,wale,dlroor pmh etc.) county env anrnenta cut t t epartrnont o 100utt�ere ins ea{
FOR WATER SUPPLY 11MLLS ONLY: lid,For Water%Veils rod over 106.000 GPI)'.Copy to DWJt,CCPC{IA-
13a,"i'leld(gpm) 0. P� Method or test• air Pamllt (gram, cI -
136.Disinfectlon type:„- HTH ArnoW:
C.'x'k CS1•; \arth Carolina Dgmuncnl OrBmvonnseataI Q-Hi '-Division of Water Resources

WELL CONSTRUCTION RECORD(GW-I) For Intmil Use Only:
I.Weil Contractor Worrrntion:
Kyle C, Sham
14,WATHR ZONES
Well Contactor Mama Mal TO DFJCti�T10N
4621-A
rL ft.
NC Well Conimetor Certifiooticn Numbs ^ 15.OUTF.A ENG(For mvlll{o sod wel OR 7L�IHR o Ikabk
Advanced Well Drilling, LLC FROM To DIAaLErER tT1[a[at:iss u7'RRiz
Caarp oay 2+a:nc
'° I Heavy. PVC
, 161TYNERCASING OR TU oternaal cksed-lo
2.Well C1gtrlctp Pemt#: � " swt ro nharQLrcnm�i-
f AIATERIAL
U9 all applicable 40 con INMan perauis(Le.U10.Caanr}:ftte,;arfnm4,.¢(a) It. la
3.Well Use(checkwell use): rt ft ii�
'Water Supply 1veilt 17,SCREIW
MOM TO DIMPTEML SLOT S E CC1��VRS9 LATERIAL
OAgriculttlral Oklunicipolthiblic FL n• 10-
DGeofhern101(Heating/Cooling Supply) 17Re1idontial Water Supply(singlo) a. MLm
E31adtstria1/Corrmhercial QResidential Water Supply(shaird) 1&CrtoVT 5
❑lsTi ion t7Wells>100 000 GPD FR* t TO ATRRIAL E6it'1ACE5N IOD dAAfOtfM
NDn-Water Supply'Veil: Bentonfte Poured
Oklpuitoring ❑Reoove n tr. �,�•
iniection MI:
R Cl ulcer >t• fL S'
eclltuge OGroundAtntcr Rawadiaticn
19.SA"/GRAYBL PACK ra ikable
❑Aquifer Starago and Reoovory OSallnityBarrier ' FROM To I UATERIAL EM1LPLIAC F Y.vT entan
OAgWler-Test OstonimuterDrainoge At tw
131EN-perimental Technology Cisubsidowe Control R 1,
EIGeothonria1(hosed loop) OTcaeer 10.DAlL,1ING LOG attach eddil[ond s eeu[rneceeaary
17G'aothennal(Haa' iCaolir Rchrm) gO1hcr( lain under 921Ranarl:s) FROM! Tn OSSciAMW odlagiwrQnga tt/rocti asim.nc
n, rc
4.Dane Welks)Completed: M# rt. ' rt.
°Sat.Well Locatton:
`S 0 q 0 IL Q• i '.
Facility/Otanrr�leme — Facility lD*(ifapplinble) n- )�O D 0- e,
n•
too
i� .l n V
AMical Address,City,and Zip 0 R Q n- -• f.
21.aj 1MAR1M
Cottity Parcel;demiLication.Na(PIN)
5h.Lutitude and longitude In degrees/minuteslscconds or d ecirml demos:
Ctf w ell field,one Wang is sufftalem) 32.Cert(licadon:
N 1Y d &-��
6.Is(ara)the reeli(s): OFernwtxnt or CITernporary gnHO�of Certarrad Well Controwor mere
INsfgfling tli[rfbm lharabv cerlbj•Uiat Lire HYll(c)tuar(ttvc)ddmvtnrwed In acrwndande erirA -
7.Is this a repair to art exls4n9 well: 171'es or G NO 1 Jd,\CAC O2C.0100 or 13.4 ArCAC 03C.0209 Wfli CanmucWx mpm lords a(ir11ha1 a Coin '
�.
Hi[r b a repafr,fill art.b>a+»+ivJi artd arFlahr Nee nahare oflhe grdrls record rw been prodded 10 rho:rie11 owner. -
rvpalr under 421 mn rl3 ndlarr ve an der bad-oflhirfornr
23.Site dingram or additimal well delalls:
6.For Geoproba/DPT or Glared-Loop Geothermal iVOls leaving ate sa no You inky use the back of this page to provide additional well mrzmofiopiafo
construolim,only I OW-1 is needed, Indicate TOTAL iv[3 MEP of A1L'lls (add'SW Over'in Rernarks Bo*.You may also attach additional pages(f n4t:essary.
dolled: fir— 24 SUBAIITTAL INSTRUCTIONS �
F =1 well depth below land sh1001(e:�6 V ( ') Subm1t Ms G%V-1 within 30 days of well completion per the following:
Fbrrrarrdple tnetlsltsf ahrlcptla t(AiQereat(motruple->�'r00'and2�100•)
10.SlalicAvaterierelbclorytopofrnsing in) 24o, For All WWI: Original fort to Division of Water Resources (Mt),
4'unferrtmisaborenoatnvarm " Information Processing Unit.1617k4SCyRaWgkNC27699-1617
11.Borehole diameter: WQ 24b.For Inlectlon Wells:Copy to DWI(,Underground Weotion cvttrol(ft-IC)
Progmm.1636:r1SC,Rafeigb,NC 276994636
12.Well catstruetiou method: z4m 24e•For Water SuEVY and Open-LooR Geodwxrnul Rchtm Wells:Copy to tllo
(ia augef,,rotuy,pole,diwo push,ma) county en oninenla th epwlznmt o e county w ere insta ed
FOR WATER SUPPLY WELLS ONLY: 241d.For Water Walls todaclnp over 4400 G D:Copy to DWR,°CCPCIIA a; '
13m Yield(gp" t� i Method of test: Air P�nrt► r Lti8 , - l
13kVslnfectlontype: HTH rnauld:
Fo:oi3R•.I North CaralinaDeptamrntofFmvonnicntalQualih•-DivWonof%%IaterResnurma • • • -•••
t ,