HomeMy WebLinkAboutGW1--02644_Well Construction - GW1_20240501 f : •
-` WELL:CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well C-mtractoPInformation:
Kyle C. Shaw -
id.WATER ZONES .1
%VellContractor Name FROM TO DESCRIPTION
4521-A 3.0c rt 50. ft. ) ev
it: a ?,H
• NC Well Contractor Ceniftcetion Number
Advanced Well Drilling, LLC IS.OUTER CASMIG-Iformulti-rased wells)OR-LINER
FROM TO DIAMETERw I THICKNESS I MATERLAL
Company'game 1- ice % 6; in. Heavy PVC
}�/ 16.INNER CASING OR TUBING(geothermal closed-loop) - •
2.Well Construction Permit#: =r �/ `- ` FROM To _DIAMETER THICKNESS MATERIAL
List all applicable:tell construction permits(Le UIC County,State,Variance.etc) D 'in'
3.Well Use(check well use): it ft. is
Water Supply Well: 17.SCREEN-
DAericaltural FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
D\•iunicipal/Public n ft. tn.
l.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) f I
t ft in
❑lndustrialCommercial ❑Residential Water Supply(shared) 1a.GROUT
Dlmeahon Dwells>100,000GPD _FROM To MATERLAL EMPLACEMrtT METHOD SAMOUKT
Non-Water Supply Well: 0' Zp Bentonite Poured
❑Monitoring El Recovery ft rt.
Injection Well: • -
DAquifer Recharge rt. ft.
Remediation
❑Aquifer Storage and Recovery19.SAND/GRAVELPACK Of applicable) = '- - '
DSalinityBarrier FROM TO ntATEIUAL EMPL.ACEMENTIMETHOD
❑Aquifer Test ❑StormunterDrainage ft. ft
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❑Experimental Technology OSubsidence Control ft. ft '
❑Geothermal(Closed Loop) ❑Tmeer 20.DRILTI.1iGLOG(attach addltionolsheets if necessary)..-:-_.'- -
DGeothermal(Heating/Cooling Return) ❑Other(explain under-21 Remarks) FROM TO DESCRn'770�(color.Lardness sowroctttspe,Erato size.etc)
8 rt 4.0 tL D:r4Aky
4.Date Well(s)Completed:3 "°La'-..24/ Well ID= 6'0 n- S ft 5.4 l
5a.Well Location 5 ft- �k- 2 }-l�,rJ /c.,c,-
1=-+�r dtJ=lt
47 4c�/L P t,iP, 6.0 i-34.,bn 73 0 ft Jos it /764-1 Q`r-C,.-J.t C (.t.
Facility/Owner Name Facility ID=(if applicable) ft f J I
l 7 5 old I 6-4-r 72,1 SlawI;c r A/c 2.c'ic a! .ft. ft.
Physical Address,City,and Zip ft. -It
Cr<a.�IJvt. 21.RE33ARIiS k :� {' ,c :,'af b__ Al
CountyParcel Identification No.(I .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l I'� U 2.024
. (if well field,one lat/long is sufficient)
22.Certification: ;r:,: : i'-:::5C. S '"K
w ,,e,44&.41.r_. ,
6.Is(are)the well(s): LPermnnent or DTemporan St_eaanzl of Ccrzitiiea Well Contractor Date
By signing t is•(ornt Ilterebv cenifythar the well(s)war(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ENo ISA NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a copy If this is a repair,fill out known well construction.tfonnation and explain the nature of the ((this record has been provided to the well owner.
repair under#21 remarks section or on the back oftlrisfornr.-
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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Boa).You may also attach additional pages if necessary.
drilled:
24.SUB IITTAL ucS-rRUCTIONS
9.Total well depth below land surface: -70S (ft.)
For ntnitiple wells list all depths if dfferent(example-Si1700.and 2rg)100'1 Submit this GW-1 within 30 days of Well completion per the following:
10.Static water level below top of casing: ,>V(7 24a. For All Wells: Original form;to Division of Water Resources (DWR),
Iftrnterlevel is above casing,use'= ' (R-) Information Processing Unit,16I7 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. 6
Om) 241,.For Infection Wells:Copy to DWR.Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Ai[I-41,.ni
{id auger,rotate,cable,direct push etc.) 24c.For Water Supply and Open Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 1
2,4d.For Water Wells producing over 100,000 GPD:Copy to DWR.CCPCU A
13a.Yield(•pin) >Jy'^? Method of test: Air Permit Program,1611 MSC,Raleigh,NC.27699-1611
13b.D
HTH •
lsItmfectiontspe: Amount: /A.
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`'i 3 I tiotth Carolina Department ofEnvironmental Quality-Division of Water Resources
Reaisw i5--3 ..
r t ` GASTON COUNTY DEPARTMENT OF HEALTH&HUMAN SERVICES
r )�t ENVIRONMENTAL HEALTH DIVISION
• y, 991 W.HUDSON BLVD.,GASTONIA,N.C. 28052
704-853-5200 �J -'
Permit Void After 60 Months WELL INSTALLATION OR REPAIR PERMIT
11 PEilMIT 14256
:Owner/Applicant: PQ rcLt.2 , E `-1'kar, Date: l 1 1 202 3
Mailing Address: Phone:(H) (W) -3,Z81
Lot Area ; Subdivision/Park Lot# Block#
PROPERTY LOCATION 115 (etc .e a. Rd &tm I el N(-- ,a 8(tp`F
Signature of applicant of authorized agent •
Type Size D/// epth Casing Depth
Casing Type Static Level Yield Grout
Grout Date Contractor/Driller
ITE S TC —No Scale
Distances Must Conform
To Local/State ,Codes. vim `
Most Common Examples Are: f • N1 C
tl
1. Water Tight Sewer Line 50' /��N 4o'
2, Ground Absorption (-1
Sewage System 100'
3. Building Foundations 25' ) . . ;
i
PID# 3 WI 7 ,
PIN# 3 b'90 9‘0(6- g96
GRIMG 7 St 0P �a uro
t
ProQ006J z5 r r
50 rya
This permit does not re'•vc a ra 4sI
the well/septic contr or (s e.-/, Al• '
from complying w' t all ct-
Gaston County a cl/or N �o zac
Carolina Laws ales i : / ISO' ^--,. s
Regulations d Or' nances. is i
t
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WATER SUPPLY INFORMATION:
o Well location,installation and protection must meet state and local regulations,and must be inspected and approved by a representative of
the Gaston County Healt►Department before any portion of the installation is put into use. i
• The siting of the well by the Health Department staff is to provide protection from KNOWN possible'sources of contamination. No quantity
and/or quality of water is guaranteed at any site by the Health Department.
• After the well is in service,contact the Gaston County Environmental Health Section(704-853-5200)for bacteriological and inorganic water
samples.
DATE ISSUED It ;.......7"172.7111. 1.=[ "----S fir--- 1 ! .
DATE WELL HEAID�,INSPECTION COMPL T EHS
FEE PAID$ 3 tlO - DATE I Z 2 02 RECEIPT# t q [5-t.--1 i IP#
DATE SAMPLES COLLECTED ATE OF BACTERIOLOGICAL RESULTS RESULTS