GW1--02876_Well Construction - GW1_20240510

, CONSTRUCTION RECORD GW-1
For Internal Use Only:
1.Well Contractor Information:
Kyle C. Shaw -
1J.WATER ZONES
Well Contractor Name FROM I TO I DESCRIPTION
4521-A i175 It I dsVG ft 130 9M
NC Well Contractor Certification Number rat I it I �tI
15.OUTER CASE G(for multi-cased wells)OR LINER(if applicable)
Advanced Well Drilling, LLC
FROM I TO I DIAMETER I THICKNESS I MATERIAL _
Company Name it. I .5._ ft. I 6 in. I Heavy PVC
y���yy///�h` 16•I_1NER CASING OR TUBING(neothermal closed-loop)
2.Well Constl•uction Permit-••.L�'!/�/ - )��� • FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable u211construction permits("Le.UJC.Co;,,; State.l•izdance.etc.! ft I ft I in. I
3.Well Use(check well use): ft. I it. I in I .
Water Supply Well: 17.SCREEN
gAgriculhnral FROM I TO I DIAMETER SLOT SIZE I THICKNESS I.MATERIAL
DMunicipaliPublic ft. I ft. in.
❑Geothermal(Heating/Cooling Supply) C9Residential Water Supply(single)
ft I ft in: I I
DlndustriaLiConmlercial ❑Residential Water Supply(shared)
❑litigation is.GROUT
❑Wells>100.000 GPD FROM TO I MATERIAL I EMPLLCEMEN'TMETHOD&AMOUNT Non-Water Supply Well: CJ fL ft Bentonite I Poured
❑Monitoring DRecovery
Injection Well: • n I it I
DAquifer Recharge rt. ft.
❑Groundwater Remediation
❑Aquifer Storage and Recovery 19.SAND/GRAVELPACk(jfappJicablel
DSalinih•Bather FROM I TO 1 MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnnater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothemnal(Closed Loop) ❑Tracer 20.DRILLING LO G(attach additional sheets if necessary)
❑Geotlterntal(Heating/Cooling Return) DOther(exrlain under#21 Remarks) FROM I To I DESCRIPTION!color,hardness solvracittcpe•gam size.etc/
�_ �L/ rt. �O fr. I •7r JAI
ue 4.D Well(s)Completed: ( WelI Ilk •
§ o rt fo rt. 50 taL
Sa.Well Location: Air- �-�v ft. els rr- r1ac �ol�4.
�. J'�-? '7 I t
1/ tri-71/J>7%lJ,.�l7S L.G.Cr �Df4S><6ia(j(off•- cp5 ft jl) ft I , .
Facility/Owner Name Facility-LD=(if applicable) ft ft
/� // Y� / I 4. . c i t. 9
.-� ',- C 'ram! fen/ } C kei'p+l V; I I e of 2�ga.( ft. rat
PhysicalAddress,City,and Zip ) ft ft. MA'i i L�L$
Z.;Ylcdn. 121.REM.-iRIiS
Countv Parcel identification No.(PIN") r"..<'i:.r. 00
5b.Latitude and longitude in deg ees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient)75
`
jq �,�y 22.Certification:
6.Is(are)the well(s): OPel manent or f=Temporar} Signa;t a of Certified Well Contractor Date
rsigning thisfbnn.I hereby cerajf•that the we11tr1 was(were.)constructed in accordance nit/
7.Is this a repair to art existing well D Yes or ('Q 1:._.VC.JC 02C.0100 or 15.4 NC.IC 02C.0200 Well Construction Standards and that a corn
lfthis is a repair•Jill out known well construction itfortnaeon and explain the nature of the ei this record has been provided to the fie!!owner.
repair sunder e71;entard->section or on the back oftl:is farm.
23.Site diagram or additional well details:
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info.
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only I GW-i is needed. Indicate TOT.�LL,NUMBER of wells
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land stuface: 0 5 (ft)
For multiple wells list all depths if different(example-3,rg'•=00'and_(a.100') Submit this GAS-1 within 30 days of Well completion per the following:
10.Static water level below top of casing: & 24a. For All Wells: Original form to Division of Water Resources (D4�i2).
Ifunter level is above casing use'= (It') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (m.) 24b.For Injection Wells: Copy to DWI?,Underground Injection Control (IUC)
,( �1�- Program•.1636 MSC,Raleigh,NC 27699-1636
\b 12. ell constructlon. �I method: ( 0�- I f--
(i.e.We,rotary,cable,direct push_etc.) 24c.For Water Stirpp1 and Open-Log GeothetTtstl Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
�T 24d.For Water Wells producing over'100,000 GPD:Copy to DWRCCPCUA
13a.Yield(gpm) .7�TeM Method of test Air Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: • HTH Amount: /itis
F-.-x c.F.=i ':oah Carolina Department of Environmental Quality-Division of Water Resources

1
LINCOLN COUNTY HEALTH DEPARTMENT
115 West Main Street-LINCOLNTON,N.C.28092-PHONE: [phone] i FAX: [phone]
Permit#: EHW23-05543 Parcel Id#:110523
Owner: HARRELSON FARMS LLC Phone: i •
Address: PO BOX 1187
City: CHERRYVILLE State: NC Zip: 28021
Applicant: MOTZ TROY A Phone: [phone] ( t
Address: PO BOX 1747 City: LINCOLNTON ; State: NC Zip: 28093
Location PARKER FARM RD Sub: , Lot#:
WELL CONSTRUCTION PERMIT
*THIS IS NOT A SEPTIC IMPROVEMENT PERMIT OR CONSTRUCTION AUTHORIZATION*
SS. 5 1 ,46«r -
f
1' :4Al/
/ 5'e p /
- - I <a �,
(Ai/ scot
II" , s c 40
t* ?fib Arcot I i mil
.__ J 12
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1v i 9
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.�� AckGY' aryn
Rd
MIN DISTANCE BETWEEN WATER SUPPLY AND SEPTIC 100+ (IN FEET)
CONDITIONS
1
Well must maintain 25'+from all structures and 100'+from all components of septic system
Carroll Miller
AUTHORIZED
AGENT'S lib.A--- DATE: 1 �17�2023
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.