GW1-2021-06895_Well Construction - GW1_20210505

i�'WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
M/� 14,WATER ZONES i
��Jichael tl Y• Shaw/aw FROM TO DESCRIPTION
Well Contractor Name mr. i ft. �
3232 �tr. rt.
112
NC Well Contractor Certification Number I.S.OUTER CASING(for multi wells)OR LINER(if applicable)
FROM TO OMMETER THtCKNESS MATERLIL
Advanced Well Drilling, LLC a ft. 414y ft. 6 In. Heavy PVC
Company Name 16.INNER CASING OR Tr%]NfG eothermal closed-loop)
���,a�y �}j��}} FROM TO 01AAIETER TIItCKNESs NIAT£RLNL
2.Well Construction Permit#:l a r-v o(Yr,7 N f I Q 191 ft. ft. in.
List all applicable hell construction permits(i.e.Cotigv.State,r eriance.etc.) fit. R in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DLLNIETER SLOT SIZE THICtiN'ESS AfATERrAL
in.
OAgricultural OMunicipal/Public
OGeothermal Hearin /Coolin Supply) E[Residential Water Supply single ft. fir• in.
( g g PP Y) uPP Y(single)
0Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO A1AT£RML EMPLACEMENT METHOD&AMOUNT
❑Irri ation ft- J Q fL Bentonite Poured
Non-Water Supply Well: fit. fit.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
OAquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK f a licable
FROM TO M ATERLAL EAIPLACEAiENT METHOD
OAquifer Storage and Recovery ❑Salinity,Barrier fit. fit.
OAquifcr Test OStorrtnvater Dminaee fir. et.
OExperimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary
OGeothermal(Closed Loop) OTracet FRONI TO DESCRIPTION color.hardness,solltrock a grain sire.Mot
❑Geothermal(Heating Cooling Return) ❑Other(explain under n21 RLgnalrkjs) ft o ft. I
4.Date Well(s)Completed: S`t �e11 ID# j�f I'V-3"0[.1t 1-Jq tr 5 tt. 5. ' r., _I( �+
15
fit. (^ fL `
Sa.Well Location-
4 - fit, fit.
19°"_:l fN- ft. ft.
FaciIity; uis 0er tame Facility
IDE(ifapplicable) fr. ft.
4.s=@ ft. ft. s+"' r A...S..
Physical Address,Ciq•,and Zip 21.RVNIARKS zi
<fOJO�QLM' 4Y X
County Parcel Identification No.(PIN)
--pigA
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Cert aeon: Sa:'�l
(ifwell field,one lat/[ong is sufficient) J� �,
'4D
3 5, L � N -0, 333
�� Signature of Certified«'ell Contractor Date
6.Is(arc)the well(s): oltt'ermanent or ❑Temporary By signing this form,1 hereby cerrq.j�that the nell(s)iras(here)constructed in accordance
frith 15.4 rVC4C 02C.0/00 or 15.4 ifCAC 02C.0200 Yell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 04N10 copy of this record has been pros*ided to lire well owner.
if this is a repair,fill Orin lazoun it-ell construction information and explain tire nature a(the 23.repair tinder 421remarks section oron the back ofthisform YoSitediagramor back
wee{details:
You may use the back 0f this gage t0 provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages ifnecessary.
Far irnilsple injection or non-itater srgrpty netts ONL Y uIth the same constraction.)'au can
submit one form. r� SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: c W� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudliple wells list all depths ifdifferem(maniple-3r,�300'and 2tot100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
If outer level is abase casing,use + 1617 Mail Service Centel',Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
�� above, also submit a copy of this farm within 30 days of completion of well
12.Well construction method: ��1svR� construction to the following:
(i.e.auger,rotary,cable,direct Push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY NVELLS ONLY: 1636 Mail Service Centel,Raleigh,NC 27699-1636
13a.Yield(gpm) A 1 _1 _ Method of test: Alf 24c.For Water Suoplr&Infection Wells: In addition to sending the farm to
the address(es) above, also submit one'copy of this form within 30 days of
13b.Disinfection type: HTH Amount:!( !Ey completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality! Revised Jan.2013
1

f
,. CATAWBACOUNTY Cue WELL-03.2021.146791
Public Health Department Subdivision LAKE SUPERIOR
Environmental Health Division
PO Box 399,25 Government Drive,Newton.NC 28658 PIN#i' i 369902670257
, [phone] FAX[phone] TDD(828)465-8200 LOT#.
Site Address: 6582 BARNETTE DR.CATAWBA NC 28609
f
Name on Permit CINDY NELSON
Property Size: Acres 0.58
Directions: Sherrills Ford Rd,Barefoot Rd,left on Barnette Or,3rd house on left
REPLACEMENT WELL PER Irr
REQUIRED WELL SETBACKS:
Septic Systems and RepairAreas 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 Barns 100 ft.
Lakes/Ponds 50 ft.
Streams/Brooks/Crecks/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.
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 welt.
Grouting Depth:20 feet minimum
Casing Height: 12 inches minimum above finished grade
All newly constructed private drinking water wells are required to be sampled in accordance with the North Carolina Rules Regarding Private,
Drinking water Well Testing(I SA NCAC I SA.3t100).The fee for this sampling is included in the cast of the well permit.It is the applicant or
property ow7rer'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 comas Environmental Health.
03/10/2021
Authorized State Agent Permit Issuance Date
3/10/2026'
Pumit Expiration Date
e11prilmt 03/112021 15:10
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