GW1-2021-06929_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.RVell Contractor Information:
Kyle C. Shawn --�
14.WATER ZONES
ell Contractor Name +��' FROM TO DESCRIPTIONWell
4521-A ft
NC tVcil Contractor Certification RTumber J ���� � �
Advanced Well Drilling �L r �r r(;�51C i"J t�Y�l$ FS.OITfERCASING far multi welts OR ICION S licLAT
f,. ��+ice 1}t'+ FROM TO DIAMETER THICICstEs iL TERL�L
ttt.Ali; fO fL in.
Company Name !. Heavy PVC
j rt� � 16.INl�'Et2 CASING OR TUBING eotherma[closed-loop)
2.Well Construction Permit#: r J FROM I To I DIAMETER ralchnss mATERIAL
List all applicable moll construction permits li.a fi7C,Comm;State,I'arlonce,etc) ft. fL in.
3.Well Use(check well use): ft fr in.
17.SCREEN
Water Supply A ell: FROM TO DIAi1fETER I SLOT SIZE THICh'TESS iJATERiAL
13Agriculturat rat#unioipaUPublic (t ft. In.
OGeothermal(Heatin'/Cooling Supply) MResidential Water Supply(single) ft ft. in.
13Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑ltri ation OWells>100.000 GPD FROM I TO MATERIAL ESIPLACEME.R'T METHOD B-AMOUNT
Non-Water Supply Well: rt Oxi ft Bentonite Poured
❑lvlonitoring ❑Recovery ft ft
Injection WeIl: , ft ft
0Aquifer Recharge ❑Groundlovater Remediation
19.SAtITDlGRAVELPACK fapplicable)
_
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL E&IPLACEMENT METHOD
OAquifer Test OStormivater Drainage ft. M
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DEsCRHMON(color,hardness,sollfrock type,gmla size,etc)
OGeothermal(HeatinglCooling Remm) OQAter(explain under#21 Remarks) iD n
4.Date Well(s)Completed: -,4, 4t'ell IB# ft Lie- ft ' t :'
5a,Well Location: z{u ft J� �
ft. It.
Faci/lity/ ivnerName Facility ID=(if applicable) ft. ft
Physical Address,City,and Zip ft ft
y ;vie a t 21.REMARKS
County Parcel Identification No.(P IN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.ls(are)the well(s): WlTnanent or OTernporary Siena oCertified Drell Contractor Date
/ Bvsigning thisforni,I hereby terrify Hutt the a ell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: 1 fYes or dNo 13A\-C.4C 02C.0100 or 15A A'CAC 02C.0200 Well Construction Standards and that a cape
tf this is a repair,fill out dnox7i well construction information and e77110in tine nature of the of this record has been protdded to the xep owner.
repair tinder 021 rental la section or on the back of this form
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal NVeUs having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL\I TUNIBER of Avells (add'See Overt in Remarks Box).YOU May also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ►J (ft.)
—t-- Submit this G\t'-1 within 30 days of well completion per the following:
For mnlaple wells list all depths if different(example-3/"a,,'?0�0'and 2t�100') i
10.Static water level below top of casing: N,(/ ( ) Via. For All %'Yells: Original font to Division of Water Resources (DWR).
If water level is above casing iLSe"+" Information Processing Unit,1617 MSC,Rai".NC 27699-1617
11.Borehole diameter: 6 ( ) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program.,1636 NISC,Ralcigr,NC 27699-1636
12.Well construction method: A,t— Ro {" r
24c.For Water Supply and Open-Lod p Geothermal Return Wells:Copy to the
(ic auger,rotary,cable,direct push,etc-) county environmental health department of the county where in ailed
FOR WATER SUPPLY NVELLS ONLY: 24d.For Water Wells pmducing over 100 000 GPD:Copy to DA R,CCPCUA
Alt' Permit Program 1621\1 C, etgh. C 27 -I i 1
13a.Yield(gpm) i.� -^ _ Method of test: )
13b.Disinfection type: HTH Amount: lk
Fc W N-1 \orth Carolina Department of Environmental Quality-Division of Water Resources Revised C-6 201 8

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
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Z
-.! 51 Sj
37
Pl(-
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I 4
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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
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