GW1-2022-06546_Well Construction - GW1_20220428

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kyle C. Shaw 14.WATER ZONES
FROMI TO DESCRIPTION
Well Contractor Name
4521-A _ ►�� '''
NC Well Contractor Certification Number
15.OUTER CASK G for could-eased wells) 2p licable
Advanced Well Drilling, LLC FROM I TO DIAMIEfER THIChTTESs9 ML4TER1,41,
Company Name ft. I aC) ft. 6 in- Heavy PVC
1 .INNER CASING OR TUBING( eothermal.closed-loo
2.Nell Construction Permit#: t),.l I-.id,- j�Un1 I fX n FROM TO DIAMETER I THICKNESS I AIATF.RIAL
List all applicable xell construction permits(tie.0C.Count State,l'ariance,etc.) ft ft in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROMM TO DIAMETER SLOT SIZE THICII,MESS ML4TERIAL
❑:Agricultural ❑\•funicipal/Public M rt. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fl. ;ry
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
❑hri tion ❑Wells>100,000GPD FROM I To MATERL4L EMPLACE11O METHODSAMIOuNT
Non-Water Supply 1Vell: ft. 2ff, IL Bentonite Poured
❑Monitoring ❑Recovery. f1. R
Injection Well:
ft f.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK fapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL I EMPL4CEM ENT MIETHOD
❑Aquifer Test ❑Stormw%ater Drainaee % ft.
❑EvperimentaiTechnology' ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
[]Geothermal(Heating/Cooling Return) ❑Odter(explain under 421 Remarks) FROM To DESCRIPTION(color,hardness wiurockrr e, m size,ewer
IL
f, ,t� •6r �r
4.Date Rrell(s)Completed: -/ -,A
«'ell Im ICI R ' '0
Sa.lVeII Location: J rt rr fc .
/a P
Facility/Owner 1,rame
yy� /e /Facility /ID�(ifappliccable) fL f
+vi 9- l!!„/ i C GA,>N`nnL��'L t v ft. fL
Physical Address,City,and Zip ft. ft
21.REMARKS
.Jinf 1�
f County Parcel Identification\o.(PI\)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
rf well field, sufficient
( d.one lat/lon g•is ) ((/�1(`�q� 22.Certification: s<:
�• '�". 'C?.� N (1l `s ✓rf �l `i' "A2 ^
^w
6.Is(are)the well(s): L'Pertmnent or ❑Temporary SignatA of Certdied Well Contractor ate
By signing thisform 11tereby,cerffy that the well(s)was(were)constnicted in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A VAC 02C.0100 or I SA AtCAC 02C.0200 Well Construction Standards and that a copy
1f this is a repair,fill out known well constnuction information and explain the mature of the of this record has been provided to the well owner.
repair under n21 remarks section or on the back ofthis 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 null construction info
construction,only 1 GANT-1 is needed. Indicate TOTAL\L•N•IBER of mils (add'See Over'in Remarks Boa).You may also attach additional pages if necessary.
dulled. 24.SUBMITTAL I\'STRUCTIONS
9.Total well depth below land surface: ` C�'j f� (ft.) Submit this GNV-l-within 30 days of well completion per the following:
For multiple wells Iist all depths if different(evoniple-31700'and 2@100')
U (ft.} 24a. For All Wells: Original form to Division of Water Resources (DVIR),
10.Static water level below top of casing:
Information Processing unit 16I7 MSC,Raleigh,NC 27699-1617
lfCrater level is above casing,use
11.Borehole diameter: 6 010 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC;27699-1636
12.Well construction method: A�-2,6 24c.For Water SuDi)ly and Oycn-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) I county environmental health department of the county where installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Rtells producing over 100,000 GPD:Copy to D1tirR,CCPCUA
- ---) Air Permit Prom-am,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) '9� Method of test:
13b.Disinfection type: HTH Amount: 85 i
Form GR'4 'North Carolina Department of Environmental Quality-Division of Water Resources Revised&-;101 c

9 CATAWBA COUNTY
s Public Health Department Case# WELL-12-2021-162726
i -
Environmental Health Division Subdivision A E KALE UNREC
4 PO Box 389,25 Government Drive,Newton,NC 28658 PIN# 379004633241
SM
LOT# 2
Site-Add
fee 6762 LONG ISLAND RD,CATAWBA NC 28609
Name o' DAVID BLEICHER 40
Property Sr` '. Acres 17.21
Directions:
Sherrills Ford Rd,tum on Long Island Rd,approx 1 mile on left*use drive on property on the left for access*
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 Bams 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.
i
tu,
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 828-465-8270,before drilling the well.
Grouting Depth:20 feet minimum
Casing Height: 12 inches minimum above finished grade
Aewly constructed private drinking water wells are required to be sampled in accordance with the North Carolina Rules Regarding Private
Drinking Water Well resting(15A NCAC 18A.3800).The:rce 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 is 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.
1 211 7/2 0 2 1
t Authorized StateA'gent€ '
Permit Issuance Date
12/17/2026
Permit E ¢
Xpiratiom Date
ehpennil
12/172021 11:19
S -