GW1-2021-06926_Well Construction - GW1_20210505

' I CONSTRUCTION RECORD(GW-1) For Intemal Use Only: j
1.Well Continctor Information:
Kyle C. Shaw 14.WATER ZONES
Well Contractor Name } '�, �„ FROM TO DESCRIPTION
4521-A - ; ,� �
NC Well Contractor Certification Number w9 yY
J 20Z1 tr it
5.OUTER CASING for roriltitased jreils OR LINER f a Rcable
Advanced Well Drilling, LLG �: � -; �ply, OM TO DIAMETER TI1lctavFSs .taTERM
IL , ft 6 in. Y
Company Name lJ?;y,".�%��'
Heavy PVC
16.INNER CASING OR TUBING(geothermal closed-loon)
2.Well Construction Permit#: � � '3� FROM I To DIA MER T111CKNESS atATERIAi
List all applicable viall construction perntits(i.e.G7C,Count};State,Maiiance,eta) M ft in.
3.Well Use(check well use): IL ft in.
Water Supp$•Well: 17.SCREEN
FROM TO DlAiIIEIER SLOTSTLE THICKNESS I1'L3TERiAL
DAgriculhtrai DMunicipal/Public % ft. in.
DGeothennal(Heating/Cooling Supply) aResidential Rtater Supply(single) ft 1t in.
Dlndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
DIrri tion DWells>100.000 GPD FROM TO DIATERMI MiPLACEMENT i1IETHOD s A IOUNT
Non-Water Supply We➢: fr a Bentonite Poured
❑Monitoring DRecovern, tt ft
Injection Well:
ft. ft
❑Aquifer Recharge DGroundtmater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FRo,t TO »rATERIAL EMPL4CEAMNTMMOD
❑Aquifer Test DStormwater Drainage R it
❑Experimeutal Technology ❑Subsidence Control R M
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets irnecessary
❑Geothermal(HeatinJCooline Retum) DOtiler(explain under=2.1 Remarks) FROM TO DESCRIPTION(color,bardnew,sollfrock a siu,etc))
4.Date Well(s)Completed: 1-7` Well ID# 0ft -) rt ,r gar.
5a.Well Location: F3 It 91 iL
" 3d a H�c-1c1�
Facility/Owner Name \Facility M#(ifapplicablel R• ft
n
C
Physical Address,City,and Zip D• ft-
11 f? ( a t/ 1 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one lat/long is sufficient) 22.Certification:
_ Str5"io2735; N _2�•� ���IYj W
ZAAW�� -
6.Ware)the well(s): 8 ermanent or OTempor:iry SngnatWe of Certified Well Contractor Date
Br signing this forni.I hereby tern fi that tire w-ell(s)was(were)constricted in accordance with
7.Is this a repair to an existing well: ❑Yes of fte o 1 Sri e\%C.4C 02C.0100 or 15A A`CAC 02C.0200 If'ell Constriction Standards and that a copy
Ifthis is a repair,fell out Lvrown vvell constrrction itrformation and explain the ranere ofthe ofthis record has been provided to the we11 oworer.
repair under 921 rentarla section or air the back of this forni
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional dell construction info
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of bells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBI4IITTAL INSTRUCTIONS
9.Total well depth below land surface: 3t�.5 (ft•) Submit this GNV-1 within 30 days of well completion r the
For multiple vvells list all depths if di�'erent(example-3@ 00'avid 2@100') 1� following:
10.Static water level below top of casing: (� (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water let el is above casing rise Information Processing Unit,1617 MSC,Raleigh.NC 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: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(La auger,rotary,cable,direct push,etc_) p.
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY. 24d.For Water Wells producing over 100 000 GPD:Copy to DWR,CCPCUA
Air Permit Program,1611 MSC,Raleigh_ ;'C:27699-1 6 1 1
13a.Yield(gpm) .3v Gt,'a"'I Methed of test:
13b.Disinfection type: HTHAmotmt• -2 �h
c.- ?i°_} North Carolina Department of Environmental Quality-Division of Water Resources Revised 6 5?UI S

LINCOLN COUNTY HEALTH DEPARTMENT
115 WEST MAIN STREET-LINCOLNTON,N.C.28092-PHONE:[phone]-'FAX: [phone]
Permit#: EH19-04986 Parcel id#:,86246
Owner: LKN CUSTOM HOMES INC Phone: [phone]
Address: PO BOX 1735 City: DENVER ( State: NC Zip: 28037
Applicant: Phone:
Address: City: State: Zip:
Location: BLAIR RD Sub: GOODSONS PLACE Lot# 25
Max#Bedrooms: 4 Current#of Bedrooms: 0 Water Supply: Private
CONSTRUCTION AUTHORIZATION AND WELL PERMIT
(Residential)
*Not to Scale CA VALID UNTIL 12/2/2024
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INITIAL SYSTEM Accepted DIST Gravity Serial TANK SIZE 1000 ST PT GALLONS
REPAIR SYSTEM Accepted DIST Gravity Serial MAX#OCCUPANTS 8 #OF TRENCHES 4
ABSORPTION AREA 1200 TRENCH(VVidthXLen9thXDepth) 3 It X 100 ft X 16-24 Inches on tower Sidewall
UNEVEN LINE LENGTH INFORMATION CAN BE FOUND IN CONDITIONS IF APPLICABLE.
TRENCH SPACING 9 (Minimum On Center) AGGREGATE DEPTH Inches PRODUCT Chambers or EPS
MIN DISTANCE BETWEEN WATER SUPPLY AND SEPTIC 50 (IN FEET) DESIGN FLOW 480 GPD LTAR 0.30
CONDITIONS DO NOT INSTALL WHEN WET
Must stub plumbing out on back right hand side of house as shown. Keep tank shallow to keep trench bottoms at desired
depth.Install 400'total of 25%reduction system on contour with trench bottoms at 20-2*'max.Stay 10'off any property
lines or structures,15 off any pools and 50'min off any wells.Keep well 25'min off any building foundation and 50'min
off any septic system.If any questions, please contact specialist prior to installation.
AUTHORIZED AGENTS SIGNATURES: /� t`` DATE: 9/1712020
Z ` G, rj J
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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