GW1-2021-00190_Well Construction - GW1_20210505

f
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
It. ft.
2136-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-sed wells OR LINER`d a licable
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER T®ctaVEss MATERIAL
0 ft. 75 ft. 6.125: In' SDR21 PVC
Company Name
E H 19-0 V CG V 36 16.'INNER CASING OR TUBING eothermal closed-lou
2.Well ConstructionPermit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits rt.e.UIG County.State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): fL ft in.
Water Supply Well: FROME TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural []Municipal/Public it. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. it,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring Recovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a 1ieable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control IL ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 75 it• CLAY
4.Date Well 4-19-2021 it s)Completed: Well lD# 76 405 ft. GRANITE
Sa.Well Location: ft ft. c l a; „
KARR DURWOOD ft• ft.
r
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. o A
2021
GATEWAY LN., MAIDEN ft. ft'I a v�11,3t};n i rof;cning U'ilit
Physical Address,City,and Zip ft. ft. Lei FIZ sec ton
on
LINCOLN 21.REMARKS .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cergt cation'
35.526520 N -81.166565 W ��4
j
/_-I? !
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or E]No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this 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 well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2r&100) construction to the following:
10.Static water level below top of casing: 55 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service(Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: lr construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServicelCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: AIR 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: CHLORINE Amount: 2 cups completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I

�. ftUt®NSTRUCTI®N RECORD
For Internal Use ONLY:
'Phis forrrlpnbe used for single or multiple wells
4I..g VV
Well Contractor Information:
Michael W. Shaw tiT D 14.WATER ZONES
A � . E FRONt TO DESCRIPTION
Well Contractor Name eft. ft.
3232 MAY X 5 2021 Oft. ID5 I. -sekXM
f
NC Well Contractor Certification Number I5.OUTER CASING for coil' ed wells OR LINER(if a licable)
,,.3,;'lon Pr-, cot.,. OM TO DIAMETER THICKNESS NL%T€nXL
Advanced Well Drilling, LLG�'$�'i1"`�j-13% Rjj�; � " fL 3 ft. 6 in. Heavy PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400 )
C {� 5SCREErNt'
TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: -1 l.,/, nl(� ft. In.
List all applicable nr11 cottsrntction permits f.e.Corm v,State,Mari nee,etc.) In.
3.Well Use(check well use): #u
Water Supply Well• TO DIAMETER I SLOTSIZE THICKNESS NLkTERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal ft ft.
(Heating/Cooling Supply) BResidential Water Supply(single) .
�. ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERUL ENIPLICENIEN DtETHOD&,*.MOUNT
❑irri ation 0n n• Bentonite' Poured
Non-Water Supply Well: a rc
❑Monitorina ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAN'D/GRAVEL PACK(if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO fL NI ATERLIL ENIPL•10ENIENT NIETHOD
❑Aquifer Test ❑StormwaterDrainage ft. fL
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM ss,TO DESCRIPTIO\(color•hardne soi rock 4—pa 'n size-etc.)
❑Geothermal(Heafing/Cooling Return) ❑Other(explain under p21 Remarks)
/I
4.Date Weil(s) `7 Completed: '" I"Vu 70
Welt ID# ft. iL
5a.Well Location: ft. YS
7 m5 U_ as ft. ft.
Facility/Owner y �},• Q Facility to,(ifopplicable) b ft. ft. —
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cert• ation:
(if well field,one fat/long is sulncient)
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary Br signing this form,I hereby cert fv that the trell(s)it-as(it-ere)constructed in accordance
with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 11"ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or i'No copy ojthis record has been provided to the ti•ell oirner.
If this is a repair,fill out Amairn well construction information and explain the nature of the
repair under'421 remarks section or nit the back ofthisforna 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY frith the same construction,you can
submit onefornt. ` SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: p�,J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdQerent(example-3lG00'and 2@100) construction to the following:
10.Static water level below top of casing:. 140 (ft-) Division of Water Quality,linformation Processing Unit,
If inter level is above casing,use"+ 1617 hail Service Center,Raleigh,NC 27699-1617
i
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 form within 30 days of completion of well
12.Well construction method:A-if -Pg" construction to the following:
(i.e.auger,rotary,cable,direct puSIL etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) tNl Method of test Air 24c.For Water Sunni•&Infection Wells: m addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: completion of well construction to the county health department of the county
where constructed
Form G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

{
LINCOLN COUNTY HEALTH DEPARTMENT
115 West Main Street-LINCOLNTON, N.C.28092 -PHONE: [phone]-FAX: [phone]
Permit#: EHS21-01921 Parcel Id#: 16724
Owner: REINVESTMENT TREASURES LLC Phone:
Address: 7633 MONBO RD City: CATAWBA State: NC Zip: 28673
Applicant: GAUDET MANDY Phone:
Address: 2541 LINCOLN PARK ST City: LINCOLNTON State: NC Zip: 28092
Location 2541 LINCOLN PARK ST Sub: LINCOLN PARK Lot#: PT 40&
41
WELL CONSTRUCTION PERMIT
72'
ID It-rc4e
2
20�
MIN DISTANCE BETWEEN WATER SUPPLY AND SEPTIC 5011 min (IN FEET)
F
25ft min any structural foundations and 50ft min off any wastewater systems.
Brad Hallman REHS
AUTHORIZED
AGENTS DATE: 311812021
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 VALID FOR 60
MONTHS FROM DATE IMPROVEMENT PERMIT IS ISSUED),AND WELL PERMIT IF APPLICABLE BEFORE INSTALLING THE ABOVE SITE PLAN.
it

y' WELL CONSTRUCTION RECORD(GW I) For Intemal Use Only:
1.R'ell Contractor Inforrration:
Kyle C. Shaw .
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4521-A �..�..
INC Well Contractor Certification Number
191�i1 Jt)�lt 15.OUTER CASWG formulti wells RLLAdvanced Well Drilling LL LrER ifa licable
FROM TO DIAMETER IHIChNESS NL4TERL>L
Company Name Pt LI ti' 6 ' in' I Heavy PVC
rI f J 16.I�V1!'ER CASING OR TUBING eothermal closed-1oo
2.Well Construction Permlt#: / /(J(j 1 FROM TO DIAMETER ralcxn•Fss I ;,fArERIAL
List all applicable well coitsin[ction per»uts(i.e fi7C,Cotitm;State,Parlance,eta, it ft j in.
3.«'ell Use(check well use): rt ft in.
Water Supplydltell: 17.SCREEN
❑ CUItUTflI FROM TO DIAMETER i SLOTSfZE THICh'TESS AL4TERL4L
❑Nlunicipal/Public It ft In.
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single)
ft fL in.
❑Industri81/COminereiai ❑Residential Water Supply(shared)
18.GROUT
❑hri ate ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEIIIT METHOD&A110U1\T
Non-Water Supply R'ell: ft M-�'1 ft Bentonite Poured
❑Ntonitoring ❑Recovery ft, ft
Injection Well:
0 Aq uifer Rech arge ❑ roundtNater Remediation ft ft
❑Aquifer Storage and Recovery 0 Salinity Barrier 19.SAND/GRAVEL PACK +fa licable
FROM I TO I MATERIAL E\1Pi ACE%M-T METHOD
❑Aquifer Test ❑Stotmwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control n tt
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
eothermal(HeatingiCooling Return) ❑Outer(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness solUrockty e,yam size,etc.)❑G
4.Date Well(s)Completed: 3 ;tell IDft
5a.Well Location: 3 W
ft
u
LfL
tl� � ( )r--,A r, ft
Faci/lity/) %%MerName FacilitvID=(if applicable) ft ft
ft. VL
Physical Address,City,and Zip ft ft
J i✓ir a l n 21.REMARKS
County. Parcel Identification No.(PDT)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is su fficient) 22.Certification:
�s.�12 q3a -�I-og 3 Zl3
� � -
6.ls(are)the well(s): L�Pe1Tna ent or ❑Temporary S,gna of Certified 1AW1 Contractor Date
JBvsigning this form.I hereby certify that[lie m ell(s)was(were)constricted in accordance with
7.Is this a repair to an esisting well: GYes or fat\'o 154-NVAC 02C.0100 or 1 SR NCAC 02C.0200 Well Construction Standards and that a copy
Y"'is is a repair,fill ant dnoxn w•e11 construction h9rorn[ation and explain the nature ofthe of thus record has been protdded to the well owner.
rnpair under r21 reniarla section or on the back of thus form.
23.Site diagram or additional well details:
8.For Geopr-obe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional Hell construction info
construction,only 1 GIA%-1 is needed. Indicate TOTAL 1\TUNIBER of Avells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBNIITTAL INSTRUCTIONS
9.Total well depth below land surface: I S
—(ft.)For nr Submit this GW-1 within 30 days of well completion irin'p!e wells list all depths iI differera(example-3G�00'and 2@I0 0') mp per the following:
10.Static water level below top of casing:_� ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
if water level is abm a casing•use"+,, ( ) Information Processing Unit,1617 N4SC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (�) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(ie.auger,rotary,cable,direct push,etc.) u 24c•For Water Supply and Open-Loon Geothermal.Return Wells:Copy to the
couny environmental health department of the county where mstalled
[FORWATER SUPPLY tVELLS OOZY: 24d.For Water Wells roduc' over 100 000 GPD:Copy to DW% CCPCUA
a.Yield(gpm) EJ �n Method of test: Air Permit rogram,1611\MC, eigh, C 27 -111b.Ilisinfect'on tppe: HTH Amount:
=c—C-i1'_I North Carolina Department of Environmental Quality-Division of Water Resources
Rexsei o-d-?Ol S

INCOLN COUNTY HEALTH.DEPARTMENT 302 NORTH ACADEMY STREET,SUITE B-LINCOLNTON,N.C.28092-PHONE:[phone]-FAX; 04
Permit#: EH19-D6422 (7 )736.8427
Owner. LKN CUSTOM HOMES INC Parcel Id M 100313
Phone:
Address: PO BOX 1735 City: DENVER
Applicant: ORNDORFF WAYNE C Phone: State: NC Zip: 28037
Address: P O BOX 173E City: DENVER
Location: CHRISTOPHER RD State: NC Zip: 28037
Sub: CHRISTOPHER WOODS Lot# 1
Max#Bedrooms: 4 Current#of Bedrooms: 0
- Water Supply: Private
IMPROVEMENT PERMIT, CONSTRUCTION AUTHORIZATION, AND WELL PERMIT
.�
*Not to scale � W z 1 T (Residential)
Lm G., in c CA VALID UNTIL 12/4/2024
zt-
Z
-.! 51 Sj
37
Pl(-
'
I 4
b _
W
c, �o FN a o aS c �
o 0 a H
-L l ►��
INITIAL SYSTEM pIL �IWA.ao' o
Accepted DIST Pump to pressure TANK SIZE 1000 ST 1000 Pr GALLO Scr Manifold
REPAIR SYSTEM Accepted .DIST Pump to Pressure MAX#OCCUPANTS 8
Manifold #OF TRENCHES 3
ABSORPTION AREA i200 Manifold TRENCH(WldthXLengthXDepth) 3 ft X ;
ft X 26 -Inches on Lower Sidewali
UNEVEN LINE LENGTH INFORMATION CAN 8 IN'CONDITIO APPLICABLE.
TRENCH SPACING 9 (Minimum On Center) AGGREGATE DEPTH Inches PRODUCT Chambers or EPS
MIN DISTANCE BETVdM WATER SUPPLY AND SEPTIC 100 ON FEET) DESIGN FLOW 480 GPD LTAR 0.30
CONDITIONS DO NOT INSTALL WHEN WET
Install 400'total of 251/o reduction system on contour with trench bottoms at 26"on shallow side.Stay 10'off any
property lines or structures and 100'off any wells.Keep well 100'off any part of septic system and 25'min off any
building foundation.Install float tree in pump tank.If any questions,please contact specialist prior to installation.
AUTHORIZED AGENT'S SIGNATURES: ( , " )[ f-* �f�t,5 DATA 12/4/2019
PAPROVEMENTPERMIT.AUTHORIZATIONTo 4�e�CONSTRUCT,ANDWELLCONSTRUCTIVOONrPEERRMIT-.EAACCHTHE fIMP`RO/]VEMENTPERMIT,AUTHORrZATIONTOCONSTRUCT.ANDWELLCONSTRUCTION
PERMIT ARE SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE ARE CHANGED FRO
ENVIRONMENTAL HEALTH APPROVALM THOSE SHOWN ON THESE PERMITS.CHANGES FR09ATHE ABOVE PERMITS REOIARE
THE INSTALLERS SHALL BE REQUIRED TO HAVE IM ROVEMENT PERMIT,CONSTRUCTION AUTHORIZATION(BOTH VALID FOR60 MONTHS FROM DATE
IMPROVEMENT PERMIT IS ISSUED),AND V79LL PERMIT IFAPPLICABLE BEFORE INSTALLING THE ABOVE SITE PLAN. _
;JL-/ 7ti0-01O j
9

' I CONSTRUCTION RECORD(GW-1) For Intemal Use Only: j
1.Well Continctor Information:
Kyle C. Shaw 14.WATER ZONES
Well Contractor Name } '�, �„ FROM TO DESCRIPTION
4521-A - ; ,� �
NC Well Contractor Certification Number w9 yY
J 20Z1 tr it
5.OUTER CASING for roriltitased jreils OR LINER f a Rcable
Advanced Well Drilling, LLG �: � -; �ply, OM TO DIAMETER TI1lctavFSs .taTERM
IL , ft 6 in. Y
Company Name lJ?;y,".�%��'
Heavy PVC
16.INNER CASING OR TUBING(geothermal closed-loon)
2.Well Construction Permit#: � � '3� FROM I To DIA MER T111CKNESS atATERIAi
List all applicable viall construction perntits(i.e.G7C,Count};State,Maiiance,eta) M ft in.
3.Well Use(check well use): IL ft in.
Water Supp$•Well: 17.SCREEN
FROM TO DlAiIIEIER SLOTSTLE THICKNESS I1'L3TERiAL
DAgriculhtrai DMunicipal/Public % ft. in.
DGeothennal(Heating/Cooling Supply) aResidential Rtater Supply(single) ft 1t in.
Dlndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
DIrri tion DWells>100.000 GPD FROM TO DIATERMI MiPLACEMENT i1IETHOD s A IOUNT
Non-Water Supply We➢: fr a Bentonite Poured
❑Monitoring DRecovern, tt ft
Injection Well:
ft. ft
❑Aquifer Recharge DGroundtmater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FRo,t TO »rATERIAL EMPL4CEAMNTMMOD
❑Aquifer Test DStormwater Drainage R it
❑Experimeutal Technology ❑Subsidence Control R M
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets irnecessary
❑Geothermal(HeatinJCooline Retum) DOtiler(explain under=2.1 Remarks) FROM TO DESCRIPTION(color,bardnew,sollfrock a siu,etc))
4.Date Well(s)Completed: 1-7` Well ID# 0ft -) rt ,r gar.
5a.Well Location: F3 It 91 iL
" 3d a H�c-1c1�
Facility/Owner Name \Facility M#(ifapplicablel R• ft
n
C
Physical Address,City,and Zip D• ft-
11 f? ( a t/ 1 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one lat/long is sufficient) 22.Certification:
_ Str5"io2735; N _2�•� ���IYj W
ZAAW�� -
6.Ware)the well(s): 8 ermanent or OTempor:iry SngnatWe of Certified Well Contractor Date
Br signing this forni.I hereby tern fi that tire w-ell(s)was(were)constricted in accordance with
7.Is this a repair to an existing well: ❑Yes of fte o 1 Sri e\%C.4C 02C.0100 or 15A A`CAC 02C.0200 If'ell Constriction Standards and that a copy
Ifthis is a repair,fell out Lvrown vvell constrrction itrformation and explain the ranere ofthe ofthis record has been provided to the we11 oworer.
repair under 921 rentarla section or air the back of this 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 dell construction info
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of bells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBI4IITTAL INSTRUCTIONS
9.Total well depth below land surface: 3t�.5 (ft•) Submit this GNV-1 within 30 days of well completion r the
For multiple vvells list all depths if di�'erent(example-3@ 00'avid 2@100') 1� following:
10.Static water level below top of casing: (� (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water let el is above casing rise Information Processing Unit,1617 MSC,Raleigh.NC 27699-1617
11.Borehole diameter: 6 (m) 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
(La auger,rotary,cable,direct push,etc_) p.
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY. 24d.For Water Wells producing over 100 000 GPD:Copy to DWR,CCPCUA
Air Permit Program,1611 MSC,Raleigh_ ;'C:27699-1 6 1 1
13a.Yield(gpm) .3v Gt,'a"'I Methed of test:
13b.Disinfection type: HTHAmotmt• -2 �h
c.- ?i°_} North Carolina Department of Environmental Quality-Division of Water Resources Revised 6 5?UI S

LINCOLN COUNTY HEALTH DEPARTMENT
115 WEST MAIN STREET-LINCOLNTON,N.C.28092-PHONE:[phone]-'FAX: [phone]
Permit#: EH19-04986 Parcel id#:,86246
Owner: LKN CUSTOM HOMES INC Phone: [phone]
Address: PO BOX 1735 City: DENVER ( State: NC Zip: 28037
Applicant: Phone:
Address: City: State: Zip:
Location: BLAIR RD Sub: GOODSONS PLACE Lot# 25
Max#Bedrooms: 4 Current#of Bedrooms: 0 Water Supply: Private
CONSTRUCTION AUTHORIZATION AND WELL PERMIT
(Residential)
*Not to Scale CA VALID UNTIL 12/2/2024
10
,;�;: �•'.. .. . ,• BO
o
CA o o � r'
� to � Cd . �
Pr
X o
C.
1 310514 1
- C ttl
INITIAL SYSTEM Accepted DIST Gravity Serial TANK SIZE 1000 ST PT GALLONS
REPAIR SYSTEM Accepted DIST Gravity Serial MAX#OCCUPANTS 8 #OF TRENCHES 4
ABSORPTION AREA 1200 TRENCH(VVidthXLen9thXDepth) 3 It X 100 ft X 16-24 Inches on tower Sidewall
UNEVEN LINE LENGTH INFORMATION CAN BE FOUND IN CONDITIONS IF APPLICABLE.
TRENCH SPACING 9 (Minimum On Center) AGGREGATE DEPTH Inches PRODUCT Chambers or EPS
MIN DISTANCE BETWEEN WATER SUPPLY AND SEPTIC 50 (IN FEET) DESIGN FLOW 480 GPD LTAR 0.30
CONDITIONS DO NOT INSTALL WHEN WET
Must stub plumbing out on back right hand side of house as shown. Keep tank shallow to keep trench bottoms at desired
depth.Install 400'total of 25%reduction system on contour with trench bottoms at 20-2*'max.Stay 10'off any property
lines or structures,15 off any pools and 50'min off any wells.Keep well 25'min off any building foundation and 50'min
off any septic system.If any questions, please contact specialist prior to installation.
AUTHORIZED AGENTS SIGNATURES: /� t`` DATE: 9/1712020
Z ` G, rj J
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,
iy

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use'Only: j
1.Well Contractor Information:
P
Kyle C. Shaw
C „„, 14.WATER ZONES l
FROM TO DESCRIPTION
Well Contractor Name ft
4521-A 1�."A'Y X 2021
n ft. ! r
NC Well Contractor Certification Number i �1 i sl I
r, 3;V 1 r: i G'SS I? 15.OUTER CASING for multi cased wells OR LL�TER if n lipble
Advanced Well Drilling, LLCin'��" y in s FROM TO DLtI4tEfER THICh1VESS 1LrTERLtL
�.de..t:ol� � G
Company Name ft ft 6 tn. Heavy PVC
16.INNER CASING OR TUBING eothen al closed-loop)
2.Well Construction Permit#: �-" Q FROM I TO I DIAhIEfER THICICPTss MATERIAL
List all applicable Hell eonstniction permits(i.e.1.7C Counr),State,Variance,etc i 1t• M in
3.Well Use(check well use): tt ft
in
17.SCREEN
Water Supply Well: FROM TO I DLALMUER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Pubiic ft fL in.
❑Geothemial(Heating/Cooling Supply) MResidential Water Supply(single) fL ft in.
❑IndustriallCommercial ❑Residential Water Supply(shared) 18.GROUP
Olrrigalion ❑Wells>100.000 GPD FROM TO MATERIAL F.MPLACEr*f&N'f METHOD&AMOUNT
Non-Water Supply Well: f- ft Bentonite Poured
❑Monitoring ❑Recovery fL it
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundvmter Remediation
19.S.A-NLD/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROI\I To I MATERIAL E11IPL9CEM&M'T METHOD
❑Aquifer Test ❑Stormv,,ater Drainage (L n
❑Experimental Technology ❑Subsidence Control it- n
❑Geothermal(Closed Loop) ❑Trace• 20.DRm1 r.ItvG LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness, illrack type,min size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. fL
�• Ch
4.Date Wells)Completed: '?5` Well ID# ft' E
Q41 it. fL IJ
5a.Well Location: rre
iC
-� fL R
Facility/Owner Name Facility ID=(if applicable) % ft
`` - s ft It.
Physical Address,City,and Zip
zL REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficiem) 22.Certification:
?S,4a2b"t N -'?I-i-7173 W
6.Is(are)the well(s): nPermanent or ❑Temporary Sumanafe of Certified Well Contractor Date
I3vsigning thisforni.I hereby certifi=that the well(s)was(were)constnicted in accordance ulth
7.Is this a repair to an existing well: ❑Yes or 8 No 1 SA A'CAC 02C.0100 or 1 SA A`CAC 02C:0200 IVell Constriction Standards and that a cony
Iftlds is a repair,fill ont known well constriction it formation and explain rile name of the ofthis record has been prrndded to the sell owner.
repair under 421 remarks section or on the back of this 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 hell construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NU'\4BER of vmlls (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRucrio Tsi
9.Total well depth below land surface: d� (%) Submit this GW-1 within 30 dais of well completion per the following:
For multiple wells list all depths if different(example-3(atr00'and 2@100')
10.Static water level below top of casing: (ft*) 24a. For AD Wells: Original form to Division of Water Resources (D)AM),
If nttrer level is above casing use"+" Information Processing Unit.1617 MSC,Raleigh.NC 27699-1617
11.Borehole diameter: 6 (�) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(ILIC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Arr - 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) I county environmental health department of the county where Installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing oyer`100 000 GP
rtD: R,Copy to D% CCPCUA
13a.Yield Wml) ?Method of test:
Air Perm rogram 1611 MSC,Raletgh,INC 27699-1611
13b.Disinfection type: HTH Amount: ���
North Carolina Department of Enironmental Quality-Division of Water Resources Rem-s-

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WELL CONSTRUCTION RECORD(GW-1) For intemal use Only: E
1.Well Contractor Information:
Kyle C. Shaw fl, 14.WATERZONES
Well Contractor Flame `3 ' FROM TO DESCWTION
4521-A )' o n l m
ppAYxj2021 n fL
Well Contractor Certification Numbei l��y
r+rn{ec"' '. 1_)i�1115.OUTERCASING for multi nsedvicells ORLLYER tfa livable
Advanced Well Drilling LLC FRO•I TO DlattiEtER^ THICKNESS \LaTERIAL
r.r,-a".:11 i"^ I-1A It. in, y
6 Heav PVC
Company Name .v
E���- Z �6(ti �� 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: U FROM TO DIAMETER'in.
THICKNESS AUTERUL
List all applicable well construction permits(i.e-L7C,County,State,Irariance,etc) H
3.Well Use(check well use): fL fL in.
17.SCREEN
Water Supply Well: FRO\I I TO DWNIErEit SLOT SIZE I THIC104ESS hL4TERIAL
❑Agricultural ❑\4unicipal/Public tL fL la .i
❑Geothermal(Heating/Cooling Supply) C1Residential Water Supply(single) fL fL in.
❑lndustrial/Commercial ❑Residential rater Supply(shared) 18.GROUT
01nigation 01ATells>100.000GPD FROM TO MATERLIL EMPLACEAELNTMETHOD&AMOUitT
Non-Water Supply Well: 0 ft. 6 fL Bentonite Poured
❑Monitoring ❑Recovery fL ft
Injection Well: f. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAiVD/GRAVELPACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EI LI&CEN1 OD
❑Aquifer Test ❑Storm-ater Drainage % n
❑Experimental Technology ❑Subsidence Control R v-
❑Geotheinial(Closed Loop) ❑Tracer 20.DRII LING LOG taWich additional sheets if necessary
lU
FROM TO DESCRIPTION(color,hardness soraek ix e.Yalu size,eta)
[]Geothermal(Heatiog/Cooling Return) ❑Outer(explain under=21 Remarks) tt. r'`it2
4.Date Well(s)Completed:3"� ? \yell IDr? (} ft. [ fr Hai. 41
Sa.Nell Location:
e. rL
Facility/O erName FacilimID-(ifapplicable) fL ft
Si.
Physical Address,City,and Zip ft fL
21.RENJARKS
L;i�t rai r�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s): CPermrnent or ❑Temporary KpnatA of Ccrti ied Well Contractor Date
Brsigning this forms,I hereby certii ,that the trell(s) ,vs(here)constnicted in accordance uith
7.Is this a repair to an existing well: QYes or MNo 15A,\'G4C 02C.0100 or 15A ACAC 02C.0200►Fell Constnicbon Standards and dint a coln=
If this is a repair,fill out kmoan well constniction information and explain the nature of the of this record has been protdded to the cell owner.
repair under 421 remarks section or on the back of this fornc 23.Site diagram or additional well details
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having die same You may use the back of this page to provide additional well construction info
construction,only 1 GW-i is needed. Indicate TOTAL NUMBER of nails (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: r� 24.SUBI\RTTAL INSTRUCTIONS'
9.Total well depth below land surface: Submit this GNV-1 within 30 days of well completion per the following:
For multiple wells list all depths if d{Qerent(example-3(arff 00'and?@!00')
10.Static water level below top of casing: i� (ft) 24a. For All Wells: Original form f to Division of Water Resources (DWR),
tf wirer level is water
le el be use o " Information Processing unit 1617 MSC;Raleigh,SIC 27699-1617
11.Borehole diameter: 6 gym) 24h.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
,a 1 9r �t Program 1636 MSC,Raleigh,INC 27699-1636
12.Well construction method: A!r s E, 24c.For Water SuvDIv and Oven-1,6oD Geothermal Return Wells:Copy to the
(ie auger,rotary,cable,direct push,etc.) f county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produchm over 100 000 GPD:Copy to DWR,CCPCUA
Air Permit Program 1611 a\4SC,Raleigh, tC 27699-1611
13a.Yield(gpm) 2-,1n Method of test: E
`/t HTH '
13b.Disinfection type: Amount: lhS
_1 North Carolina Department of Enivonmental Quality-Division of Water Resources Revised 6-6-201 S
E k

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6�arce#'ererit 'EFL-00�94 ;
Phang .(704)472- T
C *.r �` 28
der. TltOlr MOTZ CONSTRU ON!N city:
LlNC(ALld iOld �� NC
Adticss. Pb" i X 1 747
Phoft:
Flac�at: S
' City.
Address HLEE ME DID Lot# q$18 81�9
Loc os S'WIEE 6 PEA Cif
Sub: A .
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t £'t � F„ ' ��d�.� _�'@ � i '- ',. �..� ;•sue'.
ec
MIN DMT�10E�EY19fEE�i 1NArER SUPPLYAM SEF.nC
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vv E,JL,lL ti:G9i43 lT1l�TlTCtgN,'p1 p (/(-�' �p(��� p�y.QQ�(( i ......,
For internal Use Only:
1.Well Contractorlinformatfon:
Ghl"is Morgan
p 14:li'ATER20.M1iES
Wen Contractor Name �.,. i . FR011t I
DESCRIPTIQN
3572 To
V Ilion. 1,6 ft.
NC Well Contractor Certification Number fs�,GY X `� 2021 ft. R•
Morgan well&Pump, Inc. A� ���av�:T?g U,1111 If-OUTERcnsr'G far m7wRZsed lye lls ORLRYERar. ncablo
CompanyiVame "fv`1" i1vI1 FROR TO DIAMETER
+1 �• ft. i '1'�C[GVESS -MATERIAL
61fa in. sd21
pvc
2,WOMonstruetion Permit#: �- "RotNNER CASING OR TUB IARI(eotlterntal cT THICKNESS
List all appllcahle will constntctiat permits lt.e UIC,CouniG State,Variance,etc) fL To DIAMETER THiCifNESS IiATLII
ft. in.
3,Well Use(check well use):
ft, ft.
to
�;Jnter:apply WCll; 17.SCREEN
Agricultural DMunicipal/Public 67tQ1tt TO _DIAMETER,SLQTStZE T73ICIQCESS AtnTER1AL�>othorntat(Hcating(Co011n Supply) i ft. R• in.''
g ppy) QlResidential Water Suppty�(single)
01ndustrial/Commercial ft• ft.
DResidential Water Supply(shared)
irrigation 19.GROUT.
EtfonilDring
Voter Supply well. r•ROAt To M1IATERLIL EnteLACEnustvr AtETIIOD C AntounT
° R 20 fL
ORecovery bentontte poured
Injection Well; fL fr.
Aquifer Recharge QlGroundwaterRemediation ft. ft.
Aquifer Storage and Recovery E]ISalinity Barrier 29•S /GRAVEL pACICrfa Tieablc)
Aquifer Test FROM TO ATATERUL EAT['t DStormwater DrainageACt M1fENT M1IETHOD
ft. ft.
Experimental Technology E]ISubsidence Control
Geothermal(Closed Loop) ITtacer ft ft.
Ocothermal(Heating/Coolin Return ❑ �p MILLENC LOG(attach additional sheets If necessary)
g ) Other(explain under Q1 Remarks) TO DESCRIPTION color;han]aats,solVradc h c 9mia sun etcl
` Q ft. ft.
'I-Date Well(s)Completed: '�' 1 Well IIDw"�1a
Sa.Well Location: w^
`s'•fL 6 ft.
.,, llli3 �ft. fr.
Facility/Otvncr/Name // Facility ID"(if applicable) ft. ft.
Physical A ress,City,and Zip
t ft. ft.
It ft co
County
" Patecl Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladloag is sufficient) (� p
L �_n ZZ.Certification:
tv
6.Is(are)the�re1I(s), : Permanent or OTemporaly Siat,atu,�c ofCcrti `yen Contractor
G ate/ D c
7.Is this a repair to an By signing this,(omr.I hereby car*that the u211(s)was(toere)constricted in accordance
p C3iStlIIg wQ]IO Q1�105 Or n I°10 with ISA ArC9C 02C.0100 or 15.f NCAC 02C.0200 Well Con-Tintetion Standards and that a
ljthis is a repair,fill out imonTt[yell constnicarm injonnatiotr and ctplain the nature oft/ta cops,ojthis record has been provided to the well oamer.
repair under 1421 rentarla section or out the back ojthis form.
23.Site diagram or additional well details:
ii•For€3eoprobe/M or Closed-Loop Geothermal Wells baving the some You may use the back of this page to provide additional well site details or well
construction,only 1 GN I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' J,
r40O S BW-iT .21ST-RUCTIONS
9.Total tyell depth beloty land surface:
1%a•tnrtltiple wells list all depths ljd�erent Ceram 3tr_00 and_el0o� (f'") 242. For All ii'ells: Submit this form within 30 days of completion of well
p construction to the following
10.Static`rater level below top of casing: C6 (ft.)
[ficater level is above casing,use"+" Division of Water Resources,information Processing Unit,
1617 Mail Service Center,Raleigh,111C 27699-1617
11.Borehole diameter: 6 CID.) �
24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Welt construction method: rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY 7k•ELLS ONI i': Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Ccnter,.Raleigh,NC 27699-1636
13a.Yield{gpnl}_ s Method of test: air pressure 24c.For Water Supply&infection Wells: In addition to sending the form to
13b.Disinfection'type: granular p the address(es) above, also submit one copy of this form within 30 days of
Amount:=1 O�J- completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department offinvironmentat Quality-DivisianorWa[crRaoun:as ',,. RCVISedZ-7.•°-3°]6
f

14. WATER ZONES
FROM
+1
0
IL
ft.
fL
ft.
it.
uti.UrC'P'ION RECORD GW-1
1. Well Contractor)rnformatfon:
Chris Morgan
Well Contractor Name
3572
NC Well Contactor Certification Number
Morgan Well & Pump, inc. -,t nA i UnitCOmpanyName lytfv'il);ai?O� r` r,essing
2, Weil -Construction Permit #• f EN Z.C1 - 06 C.t c
List all a !)c
Jell Use (.heel,. well use):
Water Supply Well:
Agricultural
Geo[hetirlat (Hcatine/Coolin 1 DMunicipal/Public
g 5upP y) &Residential Water SuppIy(single)
Qlindust ial/Commercial [' Residential Water Supply (shared)
Irritation
Non Water Supply Well
[]IMonitoring
MAY X 5 2021
pp able Reconstruct/wipe/writs (i.e. WC, County. State, Parlance. etc.)
3. Y
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Hearing/Coors Return)
QlRccovcry
[Groundwater Remediation
DISalinfty Banier
QlStormwater Drainage
DISubsidence Control
QlTracer
Other (explain under ;r21 Remarics)
4. Date Well(s) Completed:''�3 14 Well rt nla
Sa. Well Location:
Facility/Owner Namc
S7?Y £
Physical Address, City. and Zip
4 C<!1.
County _
Parcel identification No. (PIN)
Sb. Latitude and longitude iR degrees/minutes/seconds or decimal degrees:
(if well field, one lot/lona is sufficient)
q 2.1 \ N -- $1-1 y1378"
6. Is(are) the woll(s) X Permanent or QI T emporary
7. Is this a repair to an existing well: J Ycs or Elio
lift is a repair, fill out known well constnrctron information and a'.plafn the nature of the
repair under *21 rentar*s section or on the back of this fora;.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 Gir-I is needed. Indicate TOTAL NUMBER of wells
drilled: '
nla
Facility TD# (ifapplicable)
Sk-4+1'0.`
Nor S1t6
W
9. Totol well depth below land surface: Z•4C) For multiple wells list all depths tfd @.. (example- erent (exam le- 3 > > (ft-)
10. Static crater level below top of casing: C Q
If wetter level is above casing, use "+" (ft.)
11. Borehole diameter: 6
12. Well construction method: rotary
(Le. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
/0
13a. Yield (gpni)
13b. Disinfection type: granular
Method of test: air pressure
Amount: `61 6't/
ft.
ft.
For internal Use Only:
TO
ft.
DESCRIPTION
IS. OUTER. CASING (Tor multi -cased svc)Is OR LINER (If.
FRODI TO DIAMETER THICKNESS
R.
ft.
ft.
ft.
S ft•
ti ft.
0 ft.
I3b ft.
ft.
s J
3 oft. S'c $-
ft.
ft.
ft. ft.
21. REMARKS
22. Certification:
Signature ofCcrtifjl:d Well Contractor
3 rt.
61/6 in-
16. INNER CASING OR TIM M
FROM TO
ft.
17.SCREEN -
FROiti TO
la. GROUTPROM TO
.
ft.
f.
R.
ft.
20 ft
ft.
ft.
sd21
dotheemal closed -loot
DIA6tETER THICKNESS
DIAMETER
In.
in.
MATERIAL
bentonite
19. SAND/GRAVEL PACIC
PROM To
ft.
ft.
in.
Ia.
SLOT SIZE
if applicable)
MATERIAL
llcablo)
MATERIAL
pvc
i ATERIAL
THICKNESS
MATERiAL
EMPLACEMENT METHOD & AntoutvI
poured
EMpLAcr•.M1iENT METHOD
20. DRILLING LOG (attach additional sheets if neces3
FROM TO DESCRIPTION Icahn; loudness,) soil/tack l 4 errio size. etc.)
▪ ft. 43 unCNA 1)714-
O ft.
4p 11 LT 741k.
Dale
SJ'signing this form, 1 hereby cert(n, that 'the we11(s) was (ivere) constructed in accordance
with 114 NCIC 02C.0100 or 154 NC/IC 02C.0200 Well Construction Standards and that o
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMIT T fl, LN'STRUC T IONS -
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, information Processing Unit,
I617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water SuDDIv & lniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of weIi construction to the county" health department of the county
where constructed.
Form OW-1
North Carolina Department of Environmental Quality - Division of Water Rrsoures
Revised 2-22-2016

well Contractor Name g , d
3572
NC Well Contractor Certification Number
Morgan Welt & Pump, Inc.
Company Name e /�
2. Well'Cunstruction Permit#: G / 1 wz i
. ��� ����, Si Itlituc IOaT RECORD GPI 1
1. Well Contractorinformation:
Chris Morgan - L
MAY X s 2021
I7 t)olt..-
rS3•)neSe ton
tali
List all applicable wall consrntction per nits (i.e. UIC, Cotunr: State. Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural
JGeathermal (Heating/Cooling Supply)
r lindustrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
'Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experhnental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
® .
Municipal/Public
esidential Water Supply(single)
DlResidential Water Supply (shared)
DtRecovcry
DlGroundwater Remediation
DlSalinity Barrier
DIStormwater Drainage
DISnbsidence Control
DlTracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: '` Well tD# a/a
5a. Well Location:
V�4:.F
Facility/Owner Name
Physical Address, City. and Zip
County
n/a
Facility iD# (if applicable)
L.'„ c.241. 4
rain SOglg
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
- 21, !'41 poi
6. Is(are) the tvdll(s) t Permanent or E3Temporaty
7. Is this a repair to an existing well; DtYcs or : No
ljtltis is a repair, fill out known well construction inlornmtlon and explain the nature ofthe
repair ander:121 remarks section or on the back of thisfonn.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW- is needed. Indicate TOTAL NUMBER of wells
drilled: '
06s
For multiple wefts list all depths (millirent (example- 3@200' and 2 tt 1001
9. Total well depth below land surface:
10. Static water level below top of casing:
if water level is above casing, use "+"
11. Borehole diameter: 6
12. Well construction method: rotary
(Le. auger, rotary, cable, direct push, etc.)
Zd
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)___ _, Method of test: air pressure
13b. Disinfection type: granular
Amount: ( GI
For Internal Use Only:
14. WATER ZONES
FROM TO
ft.
ft.
1 `l6 R.
ft.
DESCRIPTION
15..OUTER CASING (for multi-tom/wells OR
FROM TO DIAMETER LINERncabte)
THIC[4YESS AiATERIAL
+1 ft.
61/8 in' sdr21
pvc
qO rt.
16. INNER CASING OR TUBING (
FROM TO
ft.
ft.
I7. SCREEN
FROM f z
ft.
ft.
10. GROUT
FROM ro
0 ft.
ft.
ft.
ft.
ft.
n.
ft.
20 ft.
rt.
eothermnl closed-loo
DIAMETER THiCIWESS
in.
DIAMETER
in.
in.
MATERIAL
bentonite
in.
SLOT SIZE
19. SAPiD/GRAVEL PACIC(ifapalicable)
FROM TO MATERIAL
ft.
ft.
ft.
ft.
MATERIAL
THICKNESS
MATERIAL
EMPLACEMENT METHOD St AMOUNT
poured
EMPLAcr•.at$N -r METHOD
20. DRILLING LOG (attach additional sheets If necessary)
FROM TO DESCRIPTION {calo , hardy esssoillroclt rr c. rain sirs, eta)
6 ft. D,��
Srec.,A_c�.
C ft. t ft.
5 tI•
ft.
ft.
ft.
ft.
ft.
ft.
ft. ft.
21. REMARKS
22. Certification:
Signature of Certif)6 i Well Contractor
Date
By signing this form, i hereby cert j that Nye wells) was (were) contrntcted in accordance
with 15A NC4C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
copy ofthis record has been provided to the''well owner.
23. Site diagram or additional well details:
You may use the back of this page to' provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply &'Infection!Wells: In addition to sending the form to
the address(es) above, also submit one copy. of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form G11t-I
North Carolina Department ofEnvironmentai Quality - Division or Water Resources
Revised 2-22-2016

M. X 5 2021
7,r7.R,Gsing Unit
a))vi ,.�A
secton
Z. Well'Construction Permit#: vim` �-1
List all applicable fret/construction permits (i.e. UiC, County. State. Variance. etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
(DGeothermat (Heating/Cooling Supply)
Qindustrial/Commercial
litigation
Non Water Supply Well:
DIMonitoring
. ti.vyiv a a aJ+<:'l'Ji ON RECORD D GW 1
2. Well Contractorilrtformation:
Chris Morgan
Well Contractor Name
3572
NC Well Contractor Certification Number
Morgan Well & Pump, Inc.
Company Name
Injection Well:
Aquifer Recharge
)Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
]I Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed:
Sa. Well Location:
DMunicipal/Public
Rat8esidential Water Supply -(single)
DResidential Water Supply (shared)
DiRecovcry
[Groundwater Remediation
QlSalinity Barrier
QlStormwater Drainage
jISubsidence Control
QITracer
Other (explain under021 Remarks)
Well ID# n/a
EA.( dt1et4
Facility/OwncrName
Facility IDS (if applicable)
C7oodsCAA Pot G;1^Go/n b„
Physical Address, City. and Zip
Li COI
n/a
County
r681�1
Parcel Identification Na. (PIN)
sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/Iong is sufficient)
15 5r cil(q r; — j 1, ► 4 L t../ -
W
6. Is(are) the Svell(s) X Permanent or DITemporary
7. Is this a repair to an existing well: E3YCS or ®'No
[Phis is a repair, fill out known well construction information and etplafn the nature oftbu
repair under'#21 remark. section or on the back of this fon&
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the some
construction, only 1 GW-1, is needed. Indicate TOTAL NUMBER of wells
drilled: r 1
9. Total well depth below land surface:
For multiple wells list all depths tfd(erent (example- 3 �00
p «_UO'mtdCal1UD')
10. Static ivater level below top of casing:
ljwvter luWel is above casing, use
11. Borehole diameter: 6
12. Well construction method: rotary
(Le. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type: granular
00 (`)
(fL)
Method of test: air pressure
Amount: �ti Oti
For Internal Use Only:
14: WATER ZONES
FROM Tn
ft.
15..ODTER
FROM
+1 ft.
CASING ffor multi -eased wefts OR LINER (Ir.
T�DIAMETER THIC[CV. ESS
61l8 tn. sd2l
16. INNER CAS NG GRIMING ( eothermai closed-loo
FROM -rn DIAMETER
THICKNESS
17. SCREEN
FRoi1 t T
ft.
ft.
III. GROUT
PROb1 TO
0 ft.
ft.
ft.
20
ft.
ft.
fL
ft.
ft
DIAMETER
in.
19. SAND/G.RAVEL PACIC
FROifr TO
11.
ft.
ft.
ft.
in.
MATERIAL
bentonite
SLOT SiZE
if anaiicable)
MATERIAL
Itcabta
MATERIAL
pvc
MATERIAL
TlucKNESS
N ATEfitAL
EMPLACEMENT METHOD & AMOUNT
poured
Eh
EMPLACEM +T METHOD
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCIPTI ti color, haNn cu, sail/cacti 1 a errio size etc.)
r ft.
S4. 0 ft.
ft.
ft.
ft.
21. REMARKS
22. ,Ce
rtification:
Signature of Getup Well Contractor
G' D lc
By signing this font:, I hereby eery that the wells) was (mere) constructed in accordance
with 1SA NCIC 02C.0100 or 1.5d NCdC 02C.0200 Well Construction Standards and that a
coPy of this record has been provided to dialed! owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBM1TTA..L INSTRUCTIONS
24a. For All 1-Vells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injecion Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunnly & Iniecdon Wells: In addition to sending the form to
the address(es) above, also submit dne copy of this form within 30 days of
completion of well construction to th'e county health department of the county
where constructed.
rt.
ft.
ft.
2 1A
Form GW-1
North Carolina Department of Environmental Quality - Division or Water Resoures
Revised 2-22-2016

Itriaation
Non -Water Supply Well:
Olivfonitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
®i Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
v r 2:41.14.1 c .P.1.&1 fatUCTION RECORD GW4
1. Well ContractorItlforntation:
Chris Morgan
Well Contractor Name
3572
NC Well Contractor Certification Number
Morgan Weil d: Pump, inc.
Company Name
For internal Use Only:
14.WATER ZONES -
FRQ
TO
DESCRIPTION
M yY X 5 2021 fL ft.
} '.or1T1;R clirTG (for multi -cased tivel2s) OR LINER fr�Dctt-able
,C:9�
r,_•fu� ,nvnl Tp )
2, Well'Construction Permit#: // Irl/ Z1- 1DDc
List all applicable ,ref! construction permits (i.e.UIC, County. State. Parlance, etc.)
3. Weil Use (check well use):
Water Supply Well:
Agricultural DMunicipal/Public
Geothermal (Heating/Cooling Supply) !Residential Water Su l ' sin le
Clndustrial/Commercial pp y ( g )
Residential Water Supply (shared)
[]!Recovery
QlGroundwater Remediation
DISalinity Barrier
DStormwater Drainage
QjSubsidence Control
DITracer
Other (explain under 021 Remarks)
4. Date Well(s) Completed: Z-" Z 1 Well It?# n/a
5a. Well Location:
�1arc-w$ PIS' lei,,
Facility/Owner Name
Physical Address, City. and Zip
/ .
Cdlfty
b Lok1
nla
Facility MDR- (if applicable)
Jos 86 23
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
_.5-S3C6 iV - gL / 727 {-z
W
6. Is(are) the well(s)C3IPermanent or 1 Temporary
7. Is this a repair to an existing well:
ales or Elio
/phis is a r epair, fill out known well construction information and i'tplain the nature of the
repair under #21 rentards section or on ilte back of this form
G. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: ' fj
9. Total well depth below land surface: J V G
ti_
for multiple wells list all depths ifdferent (example- 3 z (4)
00•a,rd,Z(a11U0�
10. Static water level below top of casing:
lfwater level is above casing, use "+"
11. Borehole diameter: 6
12. Well construction method: rotary
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpnn) .SC)Method of test: air pressure
13b. Disinfection type: granular Amount: f .c_
+1 rt.
PS Lift.
16. INNER CASING OR TUBING (,
FROM TO
ft.
ft.
1717. SCREEN
Friotut-- TO
ft.
ft.
10. GROUT .
FROM To TO
0 ft.
ft.
20
ft.
ft.
ft.
n.
ft.
sd21
eothetmal closed -loon
DIA5IETER THiCICNESS
DIAMETER THICKNESS MATERIAL
in.
61/8
DIAMETER
in.
in.
rMATERLU.
bentonite
in.
ln.
SLOT SIZE
fr. g.
19. SANr ORAIIEL PACIC(if applicable)
FROM TO MATERIAL
ft.
ft.
pvc
11ATERLIL
THICINESS
MATERIAL
EMPLACEMENT METHOD & AMOUNT
poured
E:1tPLACEMENT METHOD
ft.
ft.
20.
DRILLING
RI LIN TO DESCRIPTION
(attach additional sheets If necessary)
DESCRIPTION (color. hardness. soillrvdt ttpp ernio size. etn)
ft. � ft. A
r
2 C, ft. 6 6 it.
roWn te^1"--
ft 04- ((LoC.k-
9f ft. ;$G
ft.
ft.
et' g(4A;4
ft.
ft.
ft.
21. REMARIGS
ft.
22. Certification:
i•i"!. /•1// L /�-
Signature ofCertifj•Ed Well Contractor Date
By signing this font', 1 hereby certify that the well(s) was (were) constructed in accordance
with 154 Nc9C 02C.0100 or 15.4 MAC 02C.0200 Well Construction Standards and that o
copy ()Phis record has been prodded to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
constriction details. You may also attach additional pages if necessary.
SUBMJ-T T As. INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: in addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunnly & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to !the county health department of the county
where constructed.
Form OW-1
North Carolina Department of Environmental Quality - Division of water Resources
Revised 2-22-2016