HomeMy WebLinkAboutWELL-01-2022-163670.TIF WELL CQNSTRUCTION RECORD GAY 1
For Internal Use Only:
L well Contractor Information:
Kyle C. Shaw
Well1d.WATER ZONES
Contracts Name _FROM TO DESCRIPTION
4521-A _ 14,, fl ;F 1 ft r)r�D('-t
NC Weil Contractor Certification Number _ it J
Advanced Well Drilling, LLC IS.OUTER CASIrNG(for multl-cased wells)OR LINER Gfn livable)
�, rFRO\f TO L DI13liE7fR {r THtCt�7.F;g a1tATEWAL i
Corrpanyltiaint t tL / f- ( 6 In. I Heavy PVC
2.Well�6tLSttUCtl4IlP 1 , 16.11VSER If ACIf\GORTUBING E
ermit#: _ .� r 1-it ;` txv el �._- !! �•0 r (pother-Mai closed-loop)S:
Lis!all a h _ (l T•RDdt TO DIAMETER rmcjcrrss MATERIAL
Pp-ctiible lien pervIrs(i.e.LIIC Cmort:Stole.Variance.etc) ft
R [n.
3.Well Use(check well use)- fc iti
in
Water Supply Well: 17.SCREEN -
CD432CU1t11ral p PuIiIIC FROM TO i DLLME F.R i SLOTSI2E THICI.'�IFSS hL4TERIAL
G'Llunici nl/ r
a to ,
Geothcntal(Heattnllea DEng Supply) CI Residential Water Supply(single)C-7lrld[LSEr18UCO7nt112rC18l FL ft. i in. I
❑Residential Water Supply(shared)
ClIniRation 18_GROUT
oWeIls> 100.000GPD FROM TO acaTERIAL EMPL.4CEMIWI METHOD.0 AMOUNT
Non-Water Supply Well:
_� 3 IL `?S' fL Sentonite Poured
❑N.onitoring
Injection Well: CI Recovery,- —
❑Aquifer Reclaime ❑GroundtaterRerirediation ft I R
0Aquifer Storage and Recovery ❑Seimit}Battier 19.SAND/GRAVELPACK(irappitgble)
l3Aquifer Test DStomtuat drainage FROM ` To _ i aTF[r1a1 EMPLACEMENT err tTIOD
R. •
0Experimmital Technoloy: ❑Subsidence Control '- fI rL
C7Geothrrstra!(Closed Loop) 0 aver I `
q�� _O.DRIILL�GLpG(actac[i.rdd �
itionelshretsifneceac") .
erranln {Heatin Cooling Return) DOther(esillain under'21 Remarks1_ -F[,... To DESCRIPTION Icnbor.t3rdxesS soclrvcirrcpt.tram sire•crc}
:1.Date 1VCompleted: -. !! --y Well Mg
ft. .r� r _ I �
ells} I J , I).i
• �c 4 t` i cS�+: tom. #'
xi.Well Location: ^ �� rr_ i C/S l +,{1, L.r
, ` 'rer"io P.,'" �l ti r,Tj 1t:-
Facility/au/aft Name
` {�` S•
`/ yL Facility 113 Cif applicable)
C .,ZL.-l���tCi.l �i __ , f I
•i �. N.)r _
FL ft.1 rn
PhYs ica I Address,City.and Zip 2 ft
1 21.RL`_6
. +ARXS
Couary
Parcel IdenriticariDa,_o.lPA0
5b.Latitude and 1ongltude in degrees/minutes/seconds or decimal degrees: '
(if well Geld,one Jet/bog is suiTcient)
r� :4 22.Certif'cation:
/' ,�-
+`L
Signature: Deft6.Is(are)the well(s): Petm>ntmt Or CTemppmn
7.Ls this a repair r to an 3;:.signing this-form I lsrrby cerrff},rhof the well(s)uvs(ware)co nruucted in accordance I ish
Pmisting well: CYes or 6.o 15.4IC4CO2C_010Dor15.4NCAC1)2C.0 00 Krell CansrrucrionS7rntdardrand Ono acops.
If this is a r parr,fill otrtknunn Ica coma-nettan information m:d ecplain the roars.fair c rrds record has been provfded 10 the iiwu cm"
repair Juicie,C2J remarks section or on 1hte backofthisform_
g,For Gea 23.Site diagzarn or additional well details:
p be1DPT or Dosed-Loop Geothermal Wells havine the same You may use the backof this page to provide additional moll construction info
construction,only I G1<I-I is needed Indicate TOTAL UZ•� of Hells (add'S�Ova in 1Z narks Bm).You may also attach additional pc Res if necessary.
drilled;
9.Total well depth below land surface: i G S .SL�1D t 1AL I15TRUCTIOi\5
For mitts*welts list oil depths f ehprert(amavple-3(4200'm:d'tali 00'I (B) Submit this G{�'-1 o ithim 30 days of well completion Pk per the following:
I0. ticwaterletelbelotrtopofcasirig: 7 v� 24a. For All Wells Original farm to Division of Water Resources (DWR),
If"'�hiclLr�'°`eCaT+nR eve - (fr-) Information Processing Unit,1617MSC,Raleigh,NC27699-1617
2-lb.For Injection Wells: Copy to DWR, Undzzgraund Injection Control(IUC)
IL Borehole diameter: 6 (Let)
12.
Well c ! Pm n
era ,1536.MSC,Ralcio.h,NC 27699-1636 construction /; .6.- o f•�.{`�
Cie.nv[;c,no trey,CM We,d tee[pat* etc.) 24c.For Water SutlTly and Open-Loop Geothermal Return Wells:Copy to the
`''
FOR WATER SUPPLY WELLS ONLY; county environmental health d eat of the county where installed
24d.For Water Wells producing over 100,000 GPI}:Copy to DWRCCPCUA
13a.Yield(rpm) I,j 0,a(1 Method of test: Air Permit Proerem,1611 MSC,I2alcte}t:NC27699-I611
13l> Disinfection type: -/ HTH ,
Amount: , �•-<