GW1-2021-07296_Well Construction - GW1_20210809

For Internal Use Only:
WELL CONSTRUCTION RECORD (GW-1)
1.1Vell Conti-actor Information:
Kyle C. Shaw 14.WATER ZONES
FROIf TO DESCRIPTION
Well Contractor Name 2 tt
4521-A rt.
NC Well Contractor Certification Number 15.OUTER CASE+G for multi-cased wells OR LINER if a livable
Advanced Well Drilling, LLC FROM TD DIAr1tErER I THICKNEy AATEMAL
n
fL 6 In Heavy PVC
Company Name 2 16.INNER CASING OR TUBING eothermaLclosed-loo
$
2.WeIl Construction Permit#: `� 3 ROat TO DIAINIETER THIChNEss ;%UTERIAL
iL
List all applicable well constnrction pernrirs(i.e.LTC.Courur,State.Variance,etc.)
fL fL in.
3.NVell Use(check well use):
17.SCREE
Water Supph•Nell: FROM TO I DL4MEIER SLOT SIZE THICtu-NESS hL+,TERIAL
❑Agl•icultural ❑NMunicipal/Public fL tL in.
❑Geothermal(Heating/Cooling Supply) ISResidential Water Supply(single) fL in.
❑Industrial/Cotmnercial ❑Residential Water Supply(shared) 18.GROUT
DhTiaation ❑Wells>100.000 GPD FROM TO MATERIAL EMPLACENIENT METHOD 8 AAiOUNT
Non-Water Supply Well: rL rt Bentonite Poured
❑NMonitorine ❑Recovery ft. rL
Injection Nell: % ft
❑Aquifer Recharge ❑Groundttater Remediation 19.SANDIGRAVELPACx rifapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL ENPL4CENIENT METHOD
❑Aquifer Test ❑Stonri ater Drainage rt ft
OF-iperimetltal Technology ❑Subsidence Control M tt
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION(color,bardneM soWroc6 type.pram size,etc)
❑Geothermal(HeatingfCooling Return) ❑Other(explain underT21 Remarks) % ft
00- G
4.Date Nell(s)Completed: 'Ai-t+�� Nell ID# 1-7 S ft 1 7 6
5n
51.Well Location: owx-
Facility/Oumer Name Facility ID=(if applicable) tom-
r �g bfL IL � c' c
Physical Address,City,and Zip
Ltil 21.REMARKS
.�o ,..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
d 5 { r
(ifwell field,one latflong is sufficient) 22.Certification:
6.Is(a1e)the well(s): LLPermanent or ❑Temporary Siptianife of Certified Well Contractor Date
By signing thisfornr,l hereby verb,6-that fire hell(s)was('svere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes of 8 No 15A A%CAC 02C.0100 or 15A NCAC 02C.0200 Melt Constniction Standards and that a copy
Iftlns is a repair,fill out known well consiniction information and explain the nature ofthe ofthis record leas been provided to the cell owner.
repair-under H21 remarld section or on the back ofdris form.
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 ivell construction info
construction,only 1 GW-1 is needed. Indicate TOTAL,NUNIBER of wells (add'See Over•in Remark's Boa).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: UQ Submit this GVV-1 within 30 days of well completion per the following:
For multiple wells list all deptlss if dr jjerent(example-3@2W'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft-) Information Processing Unit,1617 NISC,Raleigh,NC 27699-1617
If inter level is above casing,use
11.Borehole diameter 6 C►n) 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
(Le auger,rotary,cable,direct pusb,etc.) county environmental health department of the county where installed
FOR 1VATER SUPPLY HELLS ONLY: 24d.For Water Wells rodu . ` over 100 000 GPD:Copy to DWTr ,CCPCUA
Air Permit Program. 1611\MSC, lei ,NC 27699-1611
13a.Yield(gpm) ?Method of test: I
13b.Disinfection type: HTH Amount: C�y c�
Fcrm Gl'-1 North Carolina Department of Environmental Quality,-Division of Water Res Revised 6-6-201 S
='

-7 Oq '0L4 0005
LINCOLN COUNTY HEALTH DEPARTMENT
115 West Main Street-LINCOLNTON,N.C.28092-PHONE:[phone]-FAX: [phone]
i
Permit#: EHW21-03583 Parcel Id#: 53620
Owner: VICTORY BAPTIST CHURCH Phone:
Address: 6041 KING WILKINSON RD City: DENVER State: NC Zip: 28037
Applicant: DAVIS MARK Phone: [phone]
Address: PO BOX 934 City: DENVER State: NC Zip: 28037
Location 6041 KING WILKINSON RD Sub: Lot#:
WELL CONSTRUCTION PER I
(t Le e- )urvu,
q06-SS PIL
0Asq
p
ki
46
PA-
MIN DISTANCE BETWEEN WATER SUPPLY AND SEPTIC 100 (IN FEET)
CONDITIONS
Britt Paige REHS
AUTHORIZED
AGENT'S DATE: 61412021
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 VAUD FOR 60
MONTHS FROM DATE IMPROVEMENT PERMIT IS ISSUED).AND WELL PERMIT IF APPLICABLE BEFORE INSTALLING THE ABOVE SITE PLAN.