WI0300475_Well Construction Record(s) (GW-1)_20240213 (2)

WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
1.NN ell Conh actor information:
Kyle C. Shaw
� 14.WATER'LO`IFS DEscRtY7lov
FRO\I TO
A ell Contractor\ame �
4521-A 55 R O
fL cs
'\C Well Contractor Certification\umber
Advanced Well Drilling, LLC FROM CISL`G for multi%', sells OR LINER
01'a 'iM1TERUL
FROM TO DLh\�� PVC
fL ft- 6 is,- Heavy
Como^m Namc
16.I:\1-Eit C�tSL\G OR TLBII\G( eothermal close)-loo `�TERtAi
2.Well Construction Permit#: r•-Ro>r TO ol-t•NfErER
77TICh1Fss
ust arr.ipplicab4 Hell rntu;n+ctioa eermits(Le.GIG Ca¢+ntr.Stare.I nrimtcr.erC i
ft. fL nn.
3.\1'cll Use(check well use): fL fL in.
li_SCREEN >LYERIAL
Water Supply\\ell: FROM TO DIAMETER SLOT SIZE THIC6TESS
❑Agricultural Municipal Public n fL
❑Geothermal(Heating Cooling Supply) ©Residential Water Supply(single) R ft-
tn.
❑badustrialiCon ULT mlercial OResidential Water Supply(shared) 18•GRID
❑irrigation O\\`ells>100.000 GPD FROM TO MATERL�L E\[PL4CF.1f EST METHOD S A\iOl'N7
Non-\1'atcr Supph R'dl:
rt- fL Bentonrte Poured
❑\Ionitorine ❑Recover fL fL
Injection\\;ell, ft fL
❑Aquifar Rechar_e ❑Groundrxater Remediation
19.SAVDIGRAVELPACK 1fa licable)
❑Aquifer Storage and Recover- ❑Solufity Barrier FROM TO NLATERIAL E\1PL\CE�IE\7 METHOD
0 Aquifer Test OStorni"werDrainaae fL fL r
❑Lxperimenial Technology ❑Subsidence Control ft. ft.
❑ ctthermal(Closes Loop) ❑Tracer '-0.DRILLI\G LOG(attach additional sheets if necessnn'
FROM TO DESCRIPTION(color,Mrdnecs soWroek n e.er,ln.dsr,etc)
XGeothermal(Heating Cooling Ratum) 00tier(ezplain under=21 Remarks) rL rL
1.Date\fell(s)Completed: 3f-23 Well Mr# fi ft.
am.Well Location: rL rL
fL 0 fL
Faeilin-JOnner\ame Facilitf]!)=(if apolieablc) ( f4 SJE
fL L
- 6`1 S n ► a rz cz Lk
Physical Address.City',xnd Zio J D rL 10 f fL
21.REMARKS 7 1 1
Couan• Parcl ldcntiric,licn Xo.(PAC) IoS_ `�' G L r0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifiveil field one lati tone is sutf+cien!) 22.Certification:
3s. r 9 I5-7S N -e>In SS spa 2=1 \V i
6.Is(arc)the wel)(s): CPCITMnent or ❑Temporhn' Signistdc of Certified Well Contractor p, —
3rsigning this)brnt I hereby crrrili-that the a ell ts)xur turre)constricted in accordance with
7.Is this a repair to an edsd ng well: GYes or �\o 15.d XCAC 02C.0100 or I Sa NC.4C 02C.0200 11 ell Construction Smnd irds and that a cop-
Olds is a repair.Jill ow knoxn It consrrt,ctton inforinatimt,vtd eip!,vin the uaa+re of tlra Oft•lids record Jess been protided to the yell owner.
repay under E21 tetrads section or oft rile back of rhis jorn
23.Site diagram or additional well details:
8.For Geoprobe/DPT or,Closed-Loop Geothermal Wells havine the same You may use the back of this page to provide additional 'all construction info
construction.only 1 G\f-1 is needed. Indicate TOTAL\UMBER of Hells (add'See over'in Rern s Box).You ntay also attach additional pages if necessan-.
drilled:
t
24.St-B\IITTAL I\STRL'CTI0-
9.Total well depth below land surface: (ft.)
Far nndnple hells lisr all d ptlu{f different feran+ple-5 a 200'and 2-a'1W) Submit this G\f-1 within 30 days of'Yell completion per the following:
10.Static water level below top of casing:.14�,0 VIL) 243. For All Wells: Original form to Division of Rater RLsources (DWR).
Ijxuter lnrl is abme casing use"-"
Information Processing Unit.1617 NISC.Ralei_gIL NC 27699-161 i
Il.Borehole diameter: 6 (In.) 24b. For lniection Wells: COP}'to D\tR Underground Iniaclion Control (IL'C)
1 Program. 1636\ISC RaleiglL\C 2 76 99-1 63 6
12.Well construction method: lac.For WaterS11 l'and O en-Loo Geothermal Return Wells.Copy he
to t
(ie auger,rotary,cable,direct push etc.) couun'envifonmAhta]health deparhnent oft a counh nilzre install
=AVATERLLLS ONLY: 2•!d.For Rater\fells 1'oduc of-er100^000GPD:CopytoD"RCCPCUA
Air Permit Program. 1611\ eliz m,; C 2 -16(`-` Method of test:HTH 11�
Amount:
`:onh Carolina Dccartmcat of Entiroruncnual Qualiy-Division of Vater Resources -_ _