GW1-2021-07841_Well Construction - GW1_20211102

WE�L CONSTRUCTION RECORD(GW-I), For Internal Use Only:
1.Well Contractor Information:
Kyle C. Shaw
14.WATER ZONES
Well Contractor Name TO DESCRIPTION
4521-A ft. iti
rt IL
NC Well Contractor Certification Number Q'
IS.OUTER CASING for mnitl ed wells OR LINER f a ticable
Advanced Well Drilling, LLC FROM To DIAMETER THICh7vU \L4TERIAL
Company Name u f6 `45 ft 6 in• Heavy PVC
16.INNER CASING OR TUBING eother al closed400
2.Well Construction Permit#: FROM To DI&IMER I TH1Ca74rss I NIATER1AL
List a.7 applicable well constnte6on permits ii.e.WC Cozingt State.Parimtce,etc..) f6 fL in.
3.Well Use(check well use): rL fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNIRSS 'NUTERIAL
❑Agricultural ❑Niunicipal/Public rt rL in
❑Geothermal(Heating/Cooling Supply) ('(Residential Water Supply(single) ft, rt. in
Alt�duslriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
171rri tion ❑Wells>100,000GPD FROM To MATERiAL EMPLACEAUMT METHOD AMOUNT
1Non-Water Supply Nitell: Z? tc fL Bentonite Poured
01%4onitoring []Recovers ft. ft.
Injection Well:
rr.
❑Aquifer Recharge ❑Groundwater Remediation fc
19.S.43NDIGRAVELPACK Ara licoble
❑Aquifer Storage and Recovery ❑Salnlitt'Battler FROM TO I MATERIAL 7 EMPLACEMENT AMMOD
❑Aquifer Test ❑Stormivater Drainage n- 2
❑EXperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessnr
❑Geothermal(Heating/Cooling Return) ❑Outer(e. lain under;21 Remarks) FROM To DESCRIPTION(corer,bardnesx wlUrnck type. size,ere
Di 4L/5 14 A"M
4.Date Well(s)Completed: 1- 1 Well ID# rc 9 n
tt
5a.Well Location: rc ft"4S t
q )
C+' �/� U 'r� •'ry O �,
Facility/Owner Name Facility)D'�(ifapplicable) '
>iP7 �C - LZ�t > li?n�nl Of` !YC 09 3 �5 lei iL ;t�d13C3 f�t'�d� rUf `\ ' rt,
Physical Address,City,and Zip rz"t'
�� f n 21.REMARKS
County Parcel Identification No.(PIN!) i 0" - 0S, R r f L 9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) t C C
�y 22.Certification: ?is
­1 _N AW'r__
X"Iz�', 10_�'d_�
6.Is(nre)the well(s)• dPerminent or OTemporary Sienatufe of Certified Well Contractor Date
Btu signing thisfornt,I hereba•certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or M No 1 SA,VCAC 02C.0100 or 1 SA AtCAC 02C.0200 Well Constniction Standards and that a copy
If this is a repair,fill out known well constnuction information and explain the nontre of rite of this record has been provided to the well owner.
repair under721 remarks section or on the back ofdtis form
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Cflosed-Loop Geothermal Wells having the same You may use the back of this page to(provide additional well construction info
construction,only 1 Gibe 1 is needed. Indicate TOTAL NVNBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBNUTTAL INSTRUCTIONS
9.Total well depth below land surface: S -G`7 (ft.)
For multiple wells list all deptlu if different(example-33@,)oo'and 2@101Y) Submit this GW-1 within 30 days of well completion per the following:
F,Ci (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),10.Static water level below top of using
Ifivater level is above casing.use"+' Information Processing Unit,1617 A4SC,Raleigh NC 27699-1617
f
11.Borehole diameter: 6 (in,) 24b.For Infection Wells: Copy to DWI,Underground hijection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: (r 04c c* 24c.For Water Supply and Open-Loop Geothermal Return titells:Copy to the
(ie auger,rotary,cable direct push,etc.) county environmental health department of the county where m talled
FOR WATER SUPPLY R'ELLS ONLY: 24d.For Water Wells roduc' over 100,000 GPD:Copy to DWI?,CCPCUA
13a.Yi�(gptn
)_Yc t pr iMethod of test: AlrPzrmtt oeratn,1611\4SC,Ralet C 27699-1 11
13b.DiecHTH
tion type: Amount:JA<
C iti? North Carolina Department of Environmental Quality-Division of Water Resources Revised ti5=Ol c

R
a'
LINCOLN-COUNTY HEALTH-DEPARTMENT
115 West Main Street-LINCOLNTON,N.C.28092-PHONE:[phone]'-FAX: [phone]
Permit#: EHW21-02451 Parcel Id#: 100952
Owner: MOUSER DEAL ENTERPRISES LLC Phone:
Address: PO BOX 578 City: LINCOLNTON State: NC Zip: 28093
Applicant: Phone:
Address: City: State: Zip:
Location STRAW FIELD TR Sub: DANIELS KNOB PHASE THREE Lot#: 8
WELL CONSTRUCTION PERMIT
o,
04
t �r ao
fi
y
MIN DISTANCE BETWEEN WATER SUPPLY AND SEPTIC 50R min (IN FEET)
CONDITIONS
Ensure that well is 25min off all structural foundations and 50ft min all portions of the wastewater system including
repair.
Brad Hallman REHS
AUTHORIZED
AGENT'S DATE: 4/1212021
SIGNATURES:
i
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.
I
1
i