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Home My WebLink AboutGW1--02648_Well Construction - GW1_20240501 • WELL CONSTRUCTION,RECORD(GW-1) For Internal Use only: 1.Well Contractor Information: Kyle C. Shaw - 1a.WATER ZONES Well Contractor Name FROM 1 TO I DESCRIPTION 4521-A a,°5 ft `-1 05 f' I 2--..3c i i rt. rt NC Well Contractor Ce,•dfication Number Advanced Well Drilling, LLC 15.OUTER CASItNG(for multi-cased ttells)ORLLNER(ifapplicable) FROM To I DIAMETER I TH[CKNFSS I MATERIAL Company Name d ft es. ft. I 6 'in. I Heavy I PVC , l 16.INNER CASING OR TUBING(geothermal closed-loop) 2.Well Construction Permit#: f d, FROM I TO I DIAMETER I THICKNESS I MATERIAL List all applicable well construction purr its(Le.UIC.Caunn;State,i$riance,etc.) It It I in. I 3.Well Use(check well use): ft It I in. Water Supply Well: 17.SCREEN Cl Agricultural FROM I TO I DIAMETER SLOT SIZE I THICKNESS 11LATERIAL QMunicipaLPublic ft ft • in. I OGeotlieemial(Heating/Cooling Supply) 121Residential Water Supply(single) ft I is in. ❑fndustrial/Colmnlercial OResidential Water Supply(shared) 18.GROUT Dhrigation DWells>100.000 GPD FROM I TO , I MATERIAL I EMPLACEMENT METHODS 4.IOU T Non-Water Supply Well: 0 ft I @,O ft' Balggafte" I Poured QMonitoring DRecovery rt. I ft- /V � ' Injection Well: - • 1" ft. ft. - ❑Aquifer Recharge ❑Groundwater Remediation QAquifer Storage and Recovery t7Salirdh Barrier 19.SAND/GRAVEL PACts(ifapplictble) FROM I TO I MATERIAL I EMPLACEMENT METHOD ❑Aquifer Test DStomntater Drainage rt. I ft ❑Experimental Technology ❑Subsidence Control It ft. ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets ifnecessarv) TO I DESCRIPTION❑Geothermal(Heating/Cooling Return) ❑Other(exlain under=21 Remarks) FROMI1 rO r(color.hardness.mtUrocktcpe,min size.etel P) fL 5 Li ft 0 lc-4(rdS i.Date WelI(s)Completed:?`�T- - ( Weli ID 5 b ft. 6 0 ft. / �K/ 5a.Well Location: 6 v rt -75 ft I ,C--L/ 2,f411.,)Q Da t,;ex Rv.c1�e,t-•-- `7� ft. 1�a �.(75- ft 1 � 2-0 Facility/Owrlet1Name Facility D=(if applicable) fL ecOC It // { 3 d c'i t !e t 1(;f 1.Fit(L.S I/Je 5eile� T'\./1 Aj(, ft ft k;. 4 ..c r ate Physical Address,City,and Zip ' ft. ft I (=ras}o n J 21.REMARKS MAY U I L624 County Parcel Identification No.(PIN) j t ; F f+ link ,e :.;1 .,..,, Sb.Latitude and longitude in degrees/minutes/seconds or decimal deaiecs: ri:' (:;3tiv (if well field,one fat/long is sufficient) 22.Certification: ,46./.44&-E_Ax-- 1 ! -3-N-ozq 6.Is(are)the well(s): nPciinanent or DTempot at} Signatt6e of Ca-tilled Well Contractor Date • 3rsieninc this tbrrn.l hereby certifi•8;at the t ellis)war(arm)constructed in accordance nit), 7.Is this a repair to an existing well: 0 Yes or f o 154,s'C.C 0?C.0100 or 15.4.\C-IC 02C.0200 Well Construction Standards and that a copy !.this is a repair.Jill out know,,well construction it formation and e vlaiu the nature of the at this record liar been provided to the well owner. repair render e21 remarks section or on the back ofthis form. 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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).1 You may also attach additional pages if necessary. drilled: 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land stuface: �a J (ft.) For multiple wells list all depths ij Bitterest(example-3;nr_00'and_ sI00') Submit this GW-1 within 30 days of n ell completion per the following: 10.Static water level below top of casing: 2V0 t ft 24a. For A11 Wells: Original form.to Division of water Resources (DWR), If nuter level is above casing use••-'. ) Information Processing Unit,16171ISC Raleigh,\C 27699-16I7 11.Borehole diameter: 6 (m,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC) `�` ) Program.1636 MSC,Raleigh,NC 27699,-1636 12.Well construction method: Ale--! ics-r-ufi (Le.auger,rotar3•,cable,direct pushL 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 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA 13a.field(gpm) (a.. 9 ! Method Permit Program, 1611 MSC,Raleigh.NC 27699-1611 J of tests Air I 13b.Disinfection-type: r HTH Amount: as- ' - Nora Carolina Department of Environmental Quality-Division of Water Resources iI' GAS ()N COUNTY )F-PARTMENT OF HEALTH & #_1illdiAN T RViCi NVIIZ()MI1 NTAL.IUFA1,Tii U11'IS I4 ION r 5- --I `J qo `j"77�( 991 NV,itiJflSl'yti ai4 g41- ?{ltlt:)^1 1A,N.tC' 'i%3i}SL d}[tr Eittf� 1 ta rr,r,f{t Yo"d altr r'( �Itwak. _ WELL INSTALLATION OR REPAIR PERMIT PLRIVIIT # 1 4278 t�v,'nerlAplslbrant.. a �' ____l'i ! - - _�- .m.____.��.__ Date: .,-i � 4m �„ Phlsne•(tI) . yY('+`��) t. (., q Niniitng Address: Dist Area .ic t J1 -_T l7,4,. �llbdivi;s4c�rtfi aril� _ PROPERTY LOC '�T1oN 39$ rJ c Y. ___ er a.0_ - e ' v`'�- _ A _ "-- -`S1 alwre r,Eapat ia br uryttererc!Apia t Sire Depth Type �-- e- --=_ V 1`tirl'Yield -� Casing Grant � � Grout Date CtontractoriDi'lll:l j ;il`tl`E SK1r:tC`t6-:ititi Ssalaw�MIMP _ "" ! To tortal *ate Codt►. '-' Afoot commis,htranipIrs Aro: —^^"�' I. kV'4tat'f l;litzrtq'f roc-- St1' 3. Grams.Ahwr ptaao L`a to 3. Ka ilktiafr1t� tr$etatien+s........... 25' • t ) \ \ RUIN al II t (;RlDir 7 , P A .„---..------),.,------ i :4.76, / ,. TItii ¢sc'.amilt th•es dot reli're the vs_ill'srptsc contractor - tram tamed iy$oS mitts ali 111 - ► - - - Glaatvwtfossars aawliaa'North 111 Caroline n1.It,utwa, ft;s ilogioits soli Ordinances• 1177! '- . .� _ ,/ - it 4 .\ i -fie t p . pNe4`+ X-'G'3j 4 .tve's csnh Ip WA 7`li;R 5'Ltrt'1'1°INFORM A I Ior; - _ • fell taratdae,artst*U'alian sail pratestius must Rsec t Itirtr istbd total re0)41lain.anal mull Ise inr•prrtr-i land approved by iA repreatnlittre sf Ilse Gaston Coast),;Isaias Dcpaarso i,x trrfurr•«ray!statics*Ilk irsltalfa!ion is yet ttatt;tc►r:, The 3146111 Of fait*fit fry the Itraittt Drpartas€af staff is is pries isle pivitetloli fro as KNOWN erosible Atsalicrs of amitosis:Alion. No gssantity switin'qu:Ilty ad'otter is guaraisasrcai at any site by tilt itettlllr Driarlcut*t.• . • After the sell is In scuts,eQRiaK1 Ilse Gessoes("mit) Environments;alexia;Soc litra(704.8 .„s_zoo)d'!r°bild,riohnleil and taa>aroAtc wa,1tr • r' ' t r Pia i°SSULW i1 2 Jtt• P/' .V2A w gilts 11.01J ,+, 1•' 'rf . ' :e - iE WEL!,HEAD INSPECTIONt_.`OMfl:i`1"'. - .- 1' -IS I�,A1D — DATE I _ RE E1Pr-,/ i9tt�� „e. -._ ipm 1,ATE,S,tt 14.1'I COLLECTED >A"t"IL•OF BACTERIOLOGICAL RE fibs:I+ RESULTS'.— .. .