GW1--02889_Well Construction - GW1_20240510

ALL COfiS 'RITCTIOI C® D1-1
For Internal Use Only:
1.Well Contractor Information:
Kyle . Shaw •
WellCenttactor idame 14.WATER ZONES !
4521-A FROMTo nEscRIPT1oN .
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1'C Well Contractor Ce.$lication Number rt. rt. ��
15.•
OUTER CASING(for mulli ca"sad Wells)OR LINER(if applicable)Well Drilling, LLt�
FROM TO . I DIAMETER I THICKNESS I MATERIAL
Company Name
• ft. -1 q ft. 6, Heavy PVC
?•Well Construction Permit:4: 5(J r— (��L',%� �-1 I s 16.Lti_1'ER CASING OR TUBING(geothermal closed-loop)List all applicable:tell construction urn,ns(Le.WC.Cann);State,Varian ce.etc 1 0\1 ft. i=o I DL4\tErER I rrnot„v I aiaTERLtL
IL in.
3.Well Use(check well use);
rt. I rt. 1 i in.
Water Supply Well:
17_SCREEN
D tlgripulhirai 1:1114unicipaL'Publio FROM I TO DIAMETER SLOT SIZE I THICKNESS I 11L4TERIAL
°Geotlieermal(Heating/Cooling Supply) C'iResidential.ZS-ater Supply(single) rt. I ft. in I
I
❑IndustrialtCommercial Ct rt.O I rt. ;;,, I
Rasidential Water Supply(shared)
Oltiisati0u IS.GRLT
Non-Water Supply 11tc1I ©ikells 100.000 GPD FROM TO
\LATER I EMPL•ICEMDT METHOD SAMOUNT
❑�tonitoriita () f` I .20 fL I _Bentononite I Poured
- Injection Well: t7Recoven' ft. r fc I I
•
❑Aquifer Recharge rt. I fz I I
❑Ground\\ater Remediation
D�quiFc'r Storage and Recovery I9.SAND/GRAVEL PACK(ifapplidable)
I7Salinity Barrier
t7rlquiferTest FROM I TO I MATERIAL I EMPL10E3IE\TMETHOD
°Stormt\ater Drainage ft_ I ft. I
°Experiltlentat Technology I
❑Subsidence Control rz I ft. I
o❑Gaoihernal(Closed Loop) ❑Tracer
Geothe)Inal(HeatindLooline20.DRILLING LOG(attach additional sheets ifnecessarr•) -
Return) ❑Otllar(e lain under 121 Remarks) FROM! I To DESCRIPTION(color.hardness,soWroch.type.eraln size.etc.)
0 IL So it
4.Date Well(s)Completed: -9 L Well �;c-�=�C_ e -r
ell Ili R fz �•
5a.Well Location: 50 16 s� j R<. .
sr rt. I -,i..,/ ft L/
nt.or-c1..,���
„-CA r:�3 �6____ 1 —7 Li II*
I a)S fL I `H n ‹
Facility•/O„..e. Name ryC � `�
_ Facility D=(ifapplicable) I rt. L ft I
t
S I�� ' a rl. 7�� �--19r, \(l I ft. I � pp _ _
Physical Address,City,and Zip
t"� 77 ,r "?
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-i-rr A�ii '1.R)rLaRI{S ft. I �..'.., ... '' .._.
County MAY t1 I[l%4
Parcel Identification No.(P )
J+gitude In deerees/mintlteslseconds or decimal degrees: !f;`� :r. .zrf'l 'K7.14r,;,-...3 ; r•;
Sb.Latitude and ion
(if well field one lattlong is sufficient)
22.Certification:
0, `1 443S- N _�O_S&._ 9 i7��6r__ f7,
6.Is(arc)the e•eil(s): LPermnnent or °Temporary W�r / <�-o(L�Si_natt;eof Certified Well Contractor Date
•
Gl-a or \o �•signing r/ris{onn,I hereby certifprhar the uellrcj gas(were)constructed in accordance with
7.Is this a repair to an existing well:
.0-this is a repair-,_Jill out known well cotsr-trcdotr intommtiorr and a plain the nature of the
1_ 02C.0100 or 1 S::d t0 the
02C.0200 fire!!Construction Standards and that a cow
repair under-21;etnvr' at tins record bras Seen provided to the well otnrer.
T seeder or on the sack of this form.
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells haoiner the same 23.Site diagram or additional well details:
construction,only be 1 G\fir 1 is osedL Indicate TOTAL e lie R oft\zlts You may use the back of this page to provide additional well construction info
drilled: (add'See Over in Remarks Box).You mai-also attach additional pages if necessary.
24.SUBNIITT_AL INSTRUCTIONS
9.Total well depth below land surface: !OS For multiple wells list oil depths it-different(crontpie-Sil 20D•and=,iip 00') (fr')
Submit this GW-1 nithin;0 days of Well completion per the following:
(
IQ Static water level below top of rasing: �t7 f 2 a. For All Wells: Original formto Division of grater Resources (D1�R)
jl water level isabove casing.use -' ') Information Processing Li i t,161 r MSC,Raleigh,NC 27699-1617
11.Borehole diameter. 6 on-) 24b.For Injection Wells: Copy to DWR Underground Injection Control(IUC)
12•Well construction.method: Fromm,1636 MSC,Raleigh,\C 27699-I636
(ie.auger,rotary,cable,direct push etc.) -1 �v.�
24c.For Water SuppIc and Open-Loop Geothermal Return Wells:Copy to the
FOR 11_1T1 R SUPPLY WELLS O county environmental health deparhnent of the county where installed
ONLY: -
13a.Yield24d•For Water Wells Dloducing over tdn 000 GPD Copy to DIU,CCPCUA
(cpm) Method of test: Air Permit Program. 1611 MSC.Rale)glr,\'G 27699-1611
I 13b.Disinfection type: HTH
Amount: )r. c
i
'North Carolina Department of Environmental Quality•-Division of Water Resources

. . ,
ICHD-Environmental Health Division Mooresville Office(704)660-3625
-----------------tearlile"Ce (;°4)878-53"456 PERMff# Osta- 2.°2•11-`16716
PRIVATE DRINKING WATER WELL PERMIT PIN# 4151 -- 17 -- 0751 Type.of Permit(circle one): Repair Abandonment
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APPLICANT/OWNER NAME: Pe cor4c. 04y fforne3 ,' ADDRESS: 121 810,Ff Ole.e.o,.., Lang Moo 4.91,-;ite ,iJ a d5.116 PHONE: (-70cAd35-Pm/
DIRECTIONS TO SITE: S o7i on Ain.yIhR ; h 6 PIA(T(Y! 'el i 3rd ,
SITE ADDRESS: 1116 "free.51de C:r -1-ct,(A4enan r.3 C. 4.1.164 SUBDIVISION: .1Ae I ly Farms Fer SECTION/LOT: --
,.., Initial Site Sketch CALL 704-664-3793 for
Sr lit or Well Head Inspections
,
o! ..,g between 8-9arn
-
GROUTING RESULTS
foraira:stisis,A 9 r
i Cl 9 b.1.flj Ct
Total Depth
lo..1).trie
—-
d ' i --Is\ - Depth of Casing
41111111N%
, IX i‘i- Yield
‘fk .
1 Notes:
,0 4
4, i .42
,i1r, ,
, .7. ,
, , ,, . s
'0 o Cod'
60 • .
•
a .
, \v I; 4. . •
o Z••-( n
le ei is NtlitAtr .,
it 175 . .5 IC
il. •? P
A° tiCiA4 \
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PERMIT CONDMONS/COMMENTS: r;/lova all Ne....AC kicll r 1..t kr • , .
WELL PERMIT ISSUED BY:__.12 ... DATE: aft 7/2it (Permit is valid for 5 years from date issued.This permit may be revoked if it is determined there has been
a material change in any fact or cir mstance upon which the permit is issued.Actions of the employees of the lredell County Health Department shall in no way be taken as a guarantee that this well will produce water
of any part or larquantity or quality or for any amount of time. Employees of the lredell County Health Department assume no liability for any damages,either direct or consequential which may be caused by this well.)
Well Contractor. CONTRACTOR CERT#: - GROUT INSPECTION BY: DATE:
OR CERTIFICATION OF GROUT NOT WITNESSED BY DEPT: 'DATE: WELL HEAD INSPECTION BY: DATE:
WELL HEAD INSPECTION(check when completed):, GROUT TO GROUND SURFACE 0 WELL CONTRACTOR ID PLATED PUMP INSTALLER ID PLATE 0 SAMPLE PORT 0
$
CERTIFICATE OF COMPLETION BY: ACCESS PORT/VENT 0 WELL SEAL 0 WELL HEAD 12 INCHES/PITLESS ADAPT-OR 8 INCHES ABOVE GRADE 0
DATE: WATER SAMPLES BY: DATE:
4 Attachments:Form SW-la(required except for abandonment10 Form GW-30 0 Water Sample Results 0 Plat 0 CALL 104-664-3703 ta"sdedule grout or well heed Inspections bebseon OM
- -- ' . — .. ., — ..,...,-=-7.-y.•.,,--1-.1.n.,,-;.,- °

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!,: 0 WPDT Screening Report
Area of Interest(AOI) Information
Area : 3,134,508.61 ft2
Feb 26 2024 10:17:45 Eastern Standard lime
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1.-1 County Boundary S rcond4N Role Interstate 0 0 67 009 a ism
lion-System Roads Pnmary Roads o 005 0, 02a.n,
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mu,c01,...m0eirtw.r.aa.e;'A owe,
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