GW1-2021-06894_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD CQW 1) For Intemal Use Only:
I
L Well contractor Wbrrnation: i
Kyle C. Shaw
14.WATER ZONES j
Nell Contractor Name FROM I TO I DESCRIPTION
4521-A Ja,�t ft 3 fL '>M
r q fL ft
NC Well Contractor Certification Number
15.OUTER CASING or inulfi<osed`wells OR LINER tf a Ilrrble
Advanced Well Drilling, LLC FROM TO DIAMETER Tln�t,�Ess .L�TEIuaL
P � BcS51B�
Company Name t:l�i + �itsl��ect;on � iti l�.� n �' in. Heavy PVC
/ ��� r q '!/�V^' `� 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#:Faa)CJ1"1l-2DA /y�a -�/ FROM TO I DIAMMER I THICKNESS MATERIAL
List all applicable well constriction pernrits(i.e.UIC,Couny;State,Variance,eta) R- IL
3.«'ell Use(check well use): ft I ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑vlunicipal/Public n ft. In.
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) M M is
❑hmdustrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑Imeation ❑Wells>100.000 GPD FROM TO MATERIAL LN&L4CEMENT METHOD B AMOMW
Non-'Pater Supply Well: 8 f. .1-0 Bentonite Poured
❑lVionitoring ❑Recovery ft n
Injection Well:
% ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK Cifapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT MEMOD
❑Aquifer Test ❑Stormwater Drainage % tt
❑Experimental Technology ❑Subsidence Control ft I it
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessnry
❑Geothermal(HeatingiCooling Return) ❑Other(explain under E21 Remarks) FROM TO DESCRIPTION color,hardness,sailtrocklype.grain size,etc)
6 IL f vD ft- rye
4.Date Well(s)Completed: 1-5—21 - Well ID# ft r
5a.Well Location: ) 1t) rut 15 n. % Re
Dr nAk smlea J ft Z tt .,CA
Facility/Owner Name FacilityID=(ifapplicable) 1•Z ft 2Z tt
b
(lglcz� 1- Avg . rs!.b•Mj+x�i�E' a960q 12y rut rr 14a. mac,
Physical Address,City,and Zip ) fL 1 ft
C. tJ}I a _ 21.REI4IARKS
County Parcel Identification No.(PI\iT) 3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one)at/long is sufficient) 22.Certification:
25- L9-:2W�L_ —N W -A�9��
6,Is(are)the well(s)• 19Pelmanent or ❑Temporary SignatWe of Certified LVell Contractor Date
Bvsigning this forma I herebv certify that the ivell(s)was,(were)constricted in accordance itith
7.Is this a repair to an eidsting well: GYes or Lei No 15A,\CAC 02C.0100 or 1 SA A'CAC 02C.0200 fflell Consiniction Standards and that a colt,
If this is a repair,fill out 1yaauw well eonstniction h formation and explain the nature of the of this record has been provided to the well ouwer.
repair under 921 remarks section or on the back of this form
23.Site diagram or additional well details:
8.For Geopr obe/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 NTUTNIBER of wills (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBD-IITTAL INSTRUCTIONS'
9.Total well depth below land surface: D oS (ft)
For multiple wells list all depths ird erein(example-3@200'mid 2@1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: y b O 24a. For All Wells: Original form to Division of Water Resources (DWR),
If ii�nter level is above casing,use"-" Information Processing Unit 1617 A4SC,Raleigh SIC 27699-1617
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: A 1 r Ro'E�l1 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie auger,rotary,cable direct push etc.) county environmental health department of the county where installed
FOR WATER SUPPLY%N ELLS ONLY: 24d.For Water Wells producine over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield m Air PCmrt rogram,1 11 A SC,Raleigb,N 27 99-1611
CgP ) --�Q�ri 1�Iethod of test: I
HTH A13b.Disinfection type: Am lount• _IS
c.—G is-I North Carolina Department ofEm-ironmental Quality-Division of Water Resources Revised 6 =01 S

- i
CATAWBACOUNTY case WELL-11-2020-141271
Public Health Department Subdivision
Environmental Health Division
PO Box 389,25 Government Drive,Newton,NC 28658 PIN# 869902564802
[phone] FAX[phone] TDD(828)465-8204 LOT 4 S
Site Address: 1600 BAREFOOT AVE,CATAWBA NC 28609
F
Maine on permit: DENNIS&SUSAN SCHRADER
Property Size: Acres 1.62
olreetlons: Sherrills Ford Rd,,Turn on Barefoot Ave,Property on Right
NEW WELL PERMIT
REQUIRED WELL SETBACKS:
Septic Systems and Repair Areas for Single Family Dwellings 50 ft. .
Septic Systems and Repair Areas for Businesses and Multi-Family Residences 100 ft.
Underground Storage Tanks 100 ft.
Animal Barns 100 ft.
Lakes/Ponds 50 ft.
Streams/Brooks/Creeks/Rivers 25 ft.
Building Foundations 25 ft.
All Other Sources of Groundwater Contamination 100 ft.
Saprolite Septic Systems and Repair Areas 100 ft.
Septic Systems and Repair Areas to Wells with 2 or more connections 100 ft.
Wells shall be constructed in accordance with state regulations:
Article 15A North Carolina Administrative Code Subchapter 2C
The well driller must verify all setbacks before drilling the well.If the well driller is unable to maintain any of
the above setbacks,contact Catawba County Environmental Health at 828465-8270,before drilling the well.
Grouting Depth:20 feet minimum
Casing Height: 12 inches minimum above finished grade
All newly constructed private drinking water wells are required to be sampled in accordance with the North Carolina Rules Regarding Private
Drinking Water Well Testing(I SA NCAC I SA.3800).The fee for this sampling is included in the cost of the well permit.It is the applicant or
property owner's responsibility to notify Environmental Health when the well ii ready for sampling.Water samples will be drawn from an outside
faucet unless otherwise specified.For questions or for more information,please contact Environmental Health.
a
11/11/2020
Authorized State Agent Permit issuance Date
11/11/2025
Permit Expiration Date
chperntit 11/11/2020 12:11
t