GW1-2021-02921_Well Construction - GW1_20210505

�. ftUt®NSTRUCTI®N RECORD
For Internal Use ONLY:
'Phis forrrlpnbe used for single or multiple wells
4I..g VV
Well Contractor Information:
Michael W. Shaw tiT D 14.WATER ZONES
A � . E FRONt TO DESCRIPTION
Well Contractor Name eft. ft.
3232 MAY X 5 2021 Oft. ID5 I. -sekXM
f
NC Well Contractor Certification Number I5.OUTER CASING for coil' ed wells OR LINER(if a licable)
,,.3,;'lon Pr-, cot.,. OM TO DIAMETER THICKNESS NL%T€nXL
Advanced Well Drilling, LLG�'$�'i1"`�j-13% Rjj�; � " fL 3 ft. 6 in. Heavy PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400 )
C {� 5SCREErNt'
TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: -1 l.,/, nl(� ft. In.
List all applicable nr11 cottsrntction permits f.e.Corm v,State,Mari nee,etc.) In.
3.Well Use(check well use): #u
Water Supply Well• TO DIAMETER I SLOTSIZE THICKNESS NLkTERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal ft ft.
(Heating/Cooling Supply) BResidential Water Supply(single) .
�. ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERUL ENIPLICENIEN DtETHOD&,*.MOUNT
❑irri ation 0n n• Bentonite' Poured
Non-Water Supply Well: a rc
❑Monitorina ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAN'D/GRAVEL PACK(if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO fL NI ATERLIL ENIPL•10ENIENT NIETHOD
❑Aquifer Test ❑StormwaterDrainage ft. fL
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM ss,TO DESCRIPTIO\(color•hardne soi rock 4—pa 'n size-etc.)
❑Geothermal(Heafing/Cooling Return) ❑Other(explain under p21 Remarks)
/I
4.Date Weil(s) `7 Completed: '" I"Vu 70
Welt ID# ft. iL
5a.Well Location: ft. YS
7 m5 U_ as ft. ft.
Facility/Owner y �},• Q Facility to,(ifopplicable) b ft. ft. —
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cert• ation:
(if well field,one fat/long is sulncient)
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary Br signing this form,I hereby cert fv that the trell(s)it-as(it-ere)constructed in accordance
with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 11"ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or i'No copy ojthis record has been provided to the ti•ell oirner.
If this is a repair,fill out Amairn well construction information and explain the nature of the
repair under'421 remarks section or nit the back ofthisforna 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY frith the same construction,you can
submit onefornt. ` SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: p�,J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdQerent(example-3lG00'and 2@100) construction to the following:
10.Static water level below top of casing:. 140 (ft-) Division of Water Quality,linformation Processing Unit,
If inter level is above casing,use"+ 1617 hail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition'to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method:A-if -Pg" construction to the following:
(i.e.auger,rotary,cable,direct puSIL etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) tNl Method of test Air 24c.For Water Sunni•&Infection Wells: m addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: completion of well construction to the county health department of the county
where constructed
Form G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

{
LINCOLN COUNTY HEALTH DEPARTMENT
115 West Main Street-LINCOLNTON, N.C.28092 -PHONE: [phone]-FAX: [phone]
Permit#: EHS21-01921 Parcel Id#: 16724
Owner: REINVESTMENT TREASURES LLC Phone:
Address: 7633 MONBO RD City: CATAWBA State: NC Zip: 28673
Applicant: GAUDET MANDY Phone:
Address: 2541 LINCOLN PARK ST City: LINCOLNTON State: NC Zip: 28092
Location 2541 LINCOLN PARK ST Sub: LINCOLN PARK Lot#: PT 40&
41
WELL CONSTRUCTION PERMIT
72'
ID It-rc4e
2
20�
MIN DISTANCE BETWEEN WATER SUPPLY AND SEPTIC 5011 min (IN FEET)
F
25ft min any structural foundations and 50ft min off any wastewater systems.
Brad Hallman REHS
AUTHORIZED
AGENTS DATE: 311812021
SIGNATURES:
IMPROVEMENT PERMIT,AUTHORIZATION TO CONSTRUCT,AND WELL CONSTRUCTION PERMIT:EACH THE IMPROVEMENT PERMIT,AUTHORIZATION TO CONSTRUCT,AND WELL
CONSTRUCTION PERMIT ARE SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE ARE CHANGED FROM THOSE SHOWN ON THESE PERMITS.CHANGES FROM THE ABOVE
PERMITS REQUIRE ENVIRONMENTAL HEALTH APPROVAL.THE INSTALLERS SHALL BE REQUIRED TO HAVE AN IMPROVEMENT PERMIT„CONSTRUCTION AUTHORIZATION(BOTH VALID FOR 60
MONTHS FROM DATE IMPROVEMENT PERMIT IS ISSUED),AND WELL PERMIT IF APPLICABLE BEFORE INSTALLING THE ABOVE SITE PLAN.
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