GW1-2021-01467_Well Construction - GW1_20210305

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Wall Contractor Atame ----- 7`
_ V 7%s ft. -7S Q It. 73/
_ 771 ft. 7 73 ft. y'j
NC Wall Contractor Certification Number 15.OUTER CASTING(for mold-caseL avegs)OR i ER(if applicable)
'I'"ADKIN WELL COMPANY, FROM To DIAMEMIR r �S"s _ i1?t1T
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Company[lame
16.INNER CASING OR TUBING(aeoth rural closed-loop)
vl/cla rt5�9a:s Lia d3D9'7'h�'�d°53'A?#$}: atr'..,� FROM TO I MMIETrR ?iUC S3 MAME`RLAL
r 5, Jt op 11cable well consiruclip¢permits(i.e.UIC Calm Srete, vmiarce,etc;! I It. �/1F ft. z 1y rm Il�1 v 6,.
,;?_i (,cbecltW01 use): ft. ra. —ia.
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7 2.(.°I79C.tEN
F.lttri3f TO Dl,.?nbIETF'.iti_ �C3.C+3':;1� � 3}I1CiiiYEcs r�a_1ag3212L
Ci h: .Itantli ❑i'/e!u;tcilt�l/�nbltc it,
I 1- c v S t— \ idtantiel l.Wale•Stt iv(single)
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C� ��atr::t-rira.(_leatin�/Coolrn� ia�ply, [�f`. � _ i;'p ( 01 ) ft. ft,
❑i!a l_!stiial/Conurercial ❑RFsidential Water Swpply(shared) 13.GROUT i
❑ i t J`
• Lit6-.i s.i i 1�3g ❑❑k Wells%100,000 GPD ,-- FROM T�L l y1is'r�n1fr,��•d�a_.v�IPI LACEME T N IT-TIVrp>'.D�a,vO�U N T
N , ata�_ N €11 AA
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1❑ i{ �echargE ❑t,ov-,stw�r..� erierltation 19.SAND/GRAVEL PACK(if applic2bl,a)
❑ ._i i_`e;Ltorage and Recovery ❑Salinity Barrier FnON1 TO l MATERIAL MWLaCEMENTMETHOD
❑Aquifer Test ❑Storrrwater Drainage ft. ft°
❑experimental Tecbnology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets it necessary
❑GeotlLeniial(Heating/Cooling Return) ❑Other(explain under P21 Remarks) FROM To DESCRIPTION(color,hardness,soillroctc type,grain size,etc.)
qq _ ft. 116 rt. Sod,/
mate Mvell(s)Completed: 2L'3 FUel11D#{ f i A ,,//!� `i ft- 3 o ft.
5a.vdell Location: . +' '' T 'q� ft. it.
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Facility/Owner Name Facility ID#(if applicable) Sr LIJ ft. -o tt J 1 e
- cA t t7 t/—�
Physical`ddress,City,and Zip ft. ft.
}, 1 1 I h< J 21.REIVIARICS �J �+
Comity -✓ Parcel Identification No.(PIN) J:)+7 � %12 .A #b r7 -�J t°� Ti3i
3b.uidiude and longitude in degrees/minutes/seconds or decimal degrees: —
(if w17
ell field,one]at/long is sufficient) �y� 22.Certification:N wr , 's-y /' W —ram /' Z s
6.is(are)the well(s): loermanent c_ ❑Temporary Sigoature of Certified Well Contractor Date
�� By sio Lino thisform,I hereby certify thou Lhe'tell(s)was(were)conshucted in accordance with
7.is this a repair-to an existing well: Dyes or IikVt3 15A NCAC 02C.0100 or 15A NCAC 02C-0.200 WeJ Construction Standards and that a copy
If dais is a repair•fill out known well construction information and explain the nature of the of this record has been provided to the well or .ier.
repair trader#21 remarks section or on the back of ihisform
23.Site diagram or additional well details:
..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
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: i A Q 24.SUBMITTAL INSTRUCTIONS
9.Tot_l Fvell depth below land surface: F a (ft.)
Fo multiple wells list all depths if d�erent(exannple-3Q200'annd 2©100� Submit this GW-1 Within 30 days of well completion per the following:
6 )(ft 24a. For All Wells: Original form to Division-of Water Resources (DWR),
Ifivater level is above casing,else Static water level below top of casing:f Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
14"+"
14.Borehole diameter: (in.) �ic" (.Q y r"24b.For Iniection Wells: Copy to DWR,Underground Injection Control(IUC)
�� ROTARY
� _ R N 1r�`/ Program,1636 MSC,Raleigh,NC 27699-1636
12,Well construction method:AI R d O T°
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing ever 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,I-,TC 27699-1611
1.3a.Yield(gpm) I,!eetllod of test: !`1S( i>tt,�'
13b.Disinfection type:
70% H D H Amount: 30 ®i, bate Site visited. /_.. �1_24
Visited bye z /
Form OW-1 North Carolina Department ofEnvironu �f Water esources Revised 6-6-2018

DIMMUS MAIME: p q Ll
ADDRESS:
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PFIONE 3 AD - 30
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INCHMP-2019 WILKES COUNTY HEALTH DEPARIM'fl'('
Environmental Health Services
306 College Street,Wilkesboro, NC 28697 Phone [phone]
WELL CONSTRUCTION PERIVOUT
This permit shall be valid for no longer than 5 years hoi-ji W
Owner; k a, .r'l_ Type of"Welk
Parcel#: Total Well Depth:-____-- Feet
Ty p Type af Casing:
9 of Application: New Reptair Casing Depth:
Abandorim f-,M jN1e,w1/,9eP;,3G9m Vit LJ Type 6f,Grout:
D rectaoi s lo Property:
Grout Depth: Feet
Method of Grouting:___
Yield: GPM
Static water Level: Feet
Subdivision:
Contractor/Driller Company:
Section: Lot:
Attachment regardinq-weil abandonment: Yes Individual Driller and Certification Number:
Type of facility this 1,vall is to serve-
t3;� Septic system permit number for this prope,rty:,
Pro erties this wel)islo,serve; 2-21
-0-—4 0 4, C
P ��— Date septic system instailed on this property:
a,/Date Issued: I i 711 EHS:
Date Grout Inspected: ' EHS:
Certification of Completion Date: EHS:
Date Water Sample Collected: EHS:
Received by Owner/Agent:_ z,, Date:
As a condition of th p arroit, MP o—woefrand_10 ferane nl�
ra aril the re ep in OeMk p�ted on.he
gmp�
or t sGtq alled- he pjermft has expired.
the well is instc
to D e.
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WILKES COU-INTYLIFAITU'DEP-,�xR'rNT-Ui rl'-V
AMPROVEINIENT PERNUITICONSTRUt__T10_N AUT-110-R-CZ,1kTION
Page I
)J
C I 50
ISSUED TO:.&1'KkJ_C_ �' LOCKTIO14T: — PARCEL I.D.
NEW EXPANST r
REPAIR- TYPE OF WATER SUPPLY
FACILITY TYPE:_Z05-raikk #BEDROOMS 17, #OCCUPANTS: &P-d.
DIASEMEEN17 YES—, NO BASEMENT FIXTURES? YES 9 NO GARBAGE DISPOSAL?YES ----"NO
(Repair)
faccept the system type and site plan/layo-at as specified on the Lmprovenlent perinit Cons-Inic-lion AuthoTization.
Own W-1 ,-gal RppTesenfative Signature:
Date:
PERMIT CONIDITICATS:
L'ra e,
AUTHORIZED^STATE AGENT:
DATE:
PERMIT VALID MR: f FIVE YEARS NO EXPIRATION
The issuance of this Improvement Permit(IP)and Construction Authorization (CA)by the Health Department in no way
guarantees issuance of others-1.0eir Mlit&The own,er/opplicant isirespousible'for C.Dntflet-ling flpprophlate govern,Ing agencies
and com pflance with their requirements. The IP and CA are subject to revocation if the site plan, plat, 03-il te e d i
3 nd R_se
changes. The 1-1-Fand CA are subject to com pliance with the provisions of the Lawsond Ru Res for Sewage Trentmwiit and
Disposal, and the conditions of this permit.As 2ton(ffl on of the IP/CA,the owner and/or applicant must mninot ,ti in the
designated reference point(s)until the wastewater system is installed or the per m2it expires.
NO GRADING OR FILLING OVER THE INITIAL NITRIFICATION FIELD OR REPAIR AREAS
SEE ATTACHED SITE PLAMLAYOUT FOR SYSTEM SPECIFICATIONS
WCH-1P/CA-#-2018

WILKES COUNTY HEALTH DEPARTMENT 7)�
IMPROVEMENT PERMIT/CONSTRUCTION AUTHORIZATION
Page of- -Z,- -
PARCELI.D. �ZZ
ISSUED TO:
NEW EXPANSION Permit Expiration Date:
Type of Wastewater System' ,S2c a +
--(Initial) (Repair)
Installation Requirements/Condifions
The construction and installation Fequke-inents ofRL Les.1950,.1952,.1954,.1955,.1956,.4957,.1958,wid.1959 are incorporated by reference into this
permit and shall be met.Systems shall be installed in accordance with the attached System layout.
Septic Tank Size:-1 gallons To'cial'french Length: ISOIS)feel Trench Widtb:_,�5 feet Trench Spacing: Feet 041 ceriter
Pump TEL,1k Size: gallons Maximum Trench Bottom Depth: L(,Anches(on lower side) Soil Cover: inches
Pump Requirements: ft.TGW vs. — G13M
inches above pipe inches tail Date:.r
Aggregate Depth: inches below pipe Issued Bvo�
System comporlents represent approximate =n,0uf,9 cirfly.Tja the systemplorto beginning the
Installatlon to insure that proper grade Is mair)-tauled.Permit V.-Cificlfor 6 yevar,-from isskjance
Septic System Setbacks C
,1470 from well & from property line A
.0 from pring A?from waterline
from uilding foundation C
from
from cutbank
�ream
1
sam
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ox
0
6C)LAD
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AMA
SCALE:
WCH-)P/CA-N#-2018