GW1--03014_Well Construction - GW1_20240520

,•j:,LL l,vly a 1 K u c:LION RECORD t a�
G�-X I For Internal Use Only:
1.Well Contractor Information:
Kyle C. Shaw I
14.WATER ZONES
Well Contractor Name FROM I TO DESCRIPTION
4521-A //3.,5n 4/)5 ft. f JvM
NC Well Contractor Certification Number %75 ft. It I .y)
LLC 15.OUTER CASING(for multZsed wells)OR LINER(if applicable)
Advanced Well Drilling,
FROM I TO I DL1MErER 1 THICKNESS I \LATER1AL
Company amc 9 It. 1 1l ft I 6 in. I Heavy I PVC
2.Well Construction Permit , !JJ U� I(j� 16.INNER CASING OR TUBING(geothermal closed-loop)
• FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits tie.LW.County.State, I ariance.etc i fL ft I in.
3.Well Use(check well use): ft. ft. I in. I I
[[titer Supply Well: 1 i.SCREEN I
❑AgriCnlh,ral FROM 1 TO DIAMETER SLOT SIZE I THICKNESS 1 .1LATERLAL
❑Municipal•Public rt. I ft. in.
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single)
❑Industrial/Commercial ft. I ft. in.
I esidenrial Water Supply(shared) I
CaR
❑Irrigation _ IS.GROUT
DR ells>100.000 GPD FRO:11 I TO I JLATERLAL I EMPLACEMEcT METHOD S AMOUNT
Non-Water Supply Well:
❑Monitorine a f` -2_6 rt. �Bentonite IPOured 5 bfs.Q6
❑Recover.- I rL I n Injection Well:
❑Aquifer Recharge ft. I rt.
Groundwater Rernliation
OAquifet Storage and Recovery ❑SnlinityBarrier 19.SA SAND/GRAVEL PACK(iifapplictblel
°Aquifer Test I FROM 1 TO f MATERIALEMPLACEMENT METHOD
❑Stormtater Drainage ft ft.. I I
°Experimental Technology DSubsidence Control (t
• ft I
❑Geotltztrnal(Closed Loop) ❑Tracer
20.DRILLING LOG(attach additional sheets if necessary)
OG tm
eotheal(I-Ieating'Cooling Return) ❑Other(e,tlain under.-'21 Remarks) FROM I TO DESCRIPTION(color,hardness snlUrtrckrrpe,eraln au,etc.)
0 ft.
I ,J. ft.
O/r'i (iao,'4. Date Well(s)Completed: 41/'61"L- 1/ Well Ii l d ) f- 116r rt. _.;,..4._.;,..4.•C'T
// Jje_
I
5a.[t'ell Location: t 165 ft. 171
7/ fL i/ d ,?J
3n:�
A45f/7 \(14., tec t tr,on 1-•71 rL ISO ft. 'girl (err QcaLV-
Faccility/Onnner/rName �f / Facility'D=(ifapplicable) ft I ft
/O'er 1 LJ t L ft I . ,.. (_ _.;:
(�1C�I.,+s4-. I MC Ecl a
Physical Address,City,and Zip ft. I ft I M It( 'G 10 4
Li>_Gs,i/r i 21.RENL1RIJS
Comity Co I �..
Parcel Identification No.i�LN) :f.:.:,
Sb.Latitude and longitude in deQr•ees/minutes/seconds or decimal degrees `T + Q
(if well field,one lat/long� N is sufficient)
?5 .4 L / S7!is - /. 2_g-3-7 i/s 22.Cet tiii tion:
S tt % c
6.Is(are)the well(s): Permanent or CTempofar, �aa eoi 2L�r Gl l
Signe:id:of Cm-tilled Well Contractor Date
C Yes or 3t•signing this-jinni.]hereby cent&that the wellts)was(werei constntcted in accordance with
7.IS this a repair to an existing,well:
Ift is is a repair.fill out brown well construction intomhation and explain the nature oldie
•
I5.4 tGC 02C been
o provided to5.4 Cthe�w 11 owner.ell Construction Standards and that a cost
repair tinder=? h orilds record has been r
1 retinal.;section or on the back ofthis form.
8.For Geoprobe/DPT or Closed-Loop Geothermal[yells having the same 23.Site dia,ram or additional well details:8.For ction.only 1 Gi[=1 is needed. Indicate TOTAL NUMBER of ells
dconstn -
rilled: You may use the back of this page to provide additional well construction info
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
24.SLB\IITTAL INSTRUCTIONS
►
9.Total well depth below land surface: -S
For multiple hells list all depths iftite rent(crumple-S1¢200'and?a 100', (ft.)
Submit this GW-1 within 30 days of well corn letion
P per the following:
10.Static water level below top of casing: n (MR),
For All Wells: Original form to Division of Water Resources ( R).
(ft') Information Processing Unit.1617 MSC,Raleigh.NC 27699-1617
!f miter level is above casing use =^
11.Borehole diameter: 6 On) 24b.For Injection Wells: Copy to DWR. Underground Injection Control (IUC)
Program. 1636 MSC.Raleigh.NC 27699_1636
12.Well construction method: `'1 i r-I Zo I'tt.t-Li
(ie auger,rotor} cable direct push etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county•environmental health department of the count'where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR_CCPCUA
13a.Yield(gpm) - p Method of test: Air Permit Procyon, 1611 \15C_Raleigh_NC 27699-1 6 1 1
13b.Disinfection type: HTH
Amount: /11a5
:::::-..3'::-: Y•oZn Carolina�arUnent of Emironinentat Quality-Division of Water Resources