GW1-2021-07298_Well Construction - GW1_20210809

,WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only: f
1.=Yell Contractor Information:
Kyle C. Shaw �� 14.NVATER ZONES
Well Contractor Nam �i �N� MOMft- TO DESCRIPTION
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4521-A C' , �'�� �\ 1 ao Z� M
NC Well Contractor Certification Number f�e��OO 15.OUTER CASING for multi wells OR LiPIER d a 6nble
Advanced Well Drilling, LLC Q� �������' FROJM TO DINNI TER TFIICI�vEss ilLATERIAL
_ ft IL i6 In, Heavy PVC
Company Name c"N+©,,�
t�tt�� C 16.INNER CASING OR TUBING eothermal.clesed-loo
2.Well Construction Permit M.� ���0 i d FRonr TO DIAMETER rH1c10vESS MATERIAL
List all applicable urll constnrction permits(i.e.GIC,Couray.State.Pariance,etc.) ft. ft in.
3.Well Use(check well use): ft' ft' in.
17.SCREEN
Water Supply Well: FROM TO DLAMETER SLOT SIZE THICIOMS MATERIiL
❑Agriculhtral ❑Municipal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) i9Residential Water Supply(single) ft ft, ;n•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi ation ❑Wells>100.000 GPD FROM TO 'MATERIAL E,MPLACERrENi'T METHOD&AMOUNIT
Non-Water Supply Well: 0 ft ,o ft Bentonite Poured
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundtxater Remediation
19.S.4rYD/GRAVELPACK do 'livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERLAL EMF1ACEJIENT METHOD
❑Aquifer Test ❑Stonnixater Drainage ft- t
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
❑Geothennal(HeatingiCooling Return) ❑Other(explain under-21 Remarks) FR°ilr ro DESCRIPTION(color,bareness sowrrock e.£rain size,etc.)
ft cJ ft ,
4.Date RTell(s)Completed: tiVell ID# 1 ft i-119
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SV 0'r
aa.Well Location: u D
i 00 ft 110 fL ��o•
Facility/Ot' vner Name Facility•11D=(if applicable) i 10 ft 1'�s ft- Cal
Physical Address,City and Zip L(D ft fL
21.REMARKS !
�„t VIC;OIh \
County Parcel Identification\a.(PIN) L l7 �O ` y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.c5-51=�RsL-� - x; r A6tk «r I--RA
6.Is(are)the well(s): EPelmrnent or GTemporary S,gnat ofCer ified Well Contractor Date
By signing this form I hereby certify that the hell(s)was(were)constnicted in accordance udth
7.Is this a repair to an existing well: CYes of 81\7o 15.4 MCAC 02C.0100 or 1 SA ATCAC 03C.0200 Melt Constriction Standards and that a copy
If this is a repair,fill out known well constniction information and explain the nature of the ofthis record has been provided to the it-ell owner
repair under 421 remarks section or on the back afth is.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 gall construction info
construction,only I GW-1 is needed. Indicate TOTAL.MAIDER of galls (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Submit this GRr-1 within 30 days of well completion the following:
For multiple wells list all depths if different(example-3L 200'and 2@100') � per �'
24a. For U Wells: Original form to Division of Water Resources (D'WR),
10.Static water level below top of casing: C'D (M) Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
If tinter level is above casing,use•'="
11.Borehole diameter- 6 rm) 24b.For Injection Wells: Copy,to DWR.Underground Injection Control(IUC)
Pro_aram 1636 MSC,Raleigh,\tC 27699-1636
12.Well construction method:A'f I�'pp t t-'� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct pusb,etc.) county environmental health department of the county'Miere installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin':;over 100.000 GPD:Copy to DVJR,CCPCUA
13a.Yield(gpm) 5 M Method of test: Air Permit ogram, 1611 MSC, eight NC 27699-1611
13b.Disinfection type: HTH Amount: 1. IL-)
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Form Gli'-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S

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LINCOLN COUNTY HEALTH DEPARTMENT
115 West Main Street-LINCOLNTON,N.C.28092-PHONE:[phone]-FAX: [phone]
Permit#: EHW21-01215 Parcel Id#: 87431
Owner. EPPERSON PATRICK M Phone: [phone]
Address: 2683 CANVASBACK LANE City: CATAWBA State: NC . Zip: 28609
Applicant: Phone:
Address: City: State: Zip:
Location SHILOH RUN LN Sub: SHILOH RUN Lot#: 24
WELL CONSTRUCTION PERMIT
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££ISIz �'� ^yti��M'"
N +D SW41
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' PL 271.73'
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MIN DISTANCE BETWEEN WATER SUPPLY AND SEPTIC 100 (IN FEET)
CONDITIONS
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Well must stay at least 25'from house&structures. Due to presence of shallow saprolite,well mutt stay 100'minimum
from all parts of the septic system.
Adam Lone :
AUTHORIZED
AGENT'S DATE: 2JI912021
SIGNATURES: V'G�
IMPROVEMENT PERMIT,AUTHORIZATION TO CONSTRUCT,AND WELL CONSTRUCTION PERMIT:EACH THE IMPROVEMENT PERMIT,AUTHORIZATION TO CONSTRUCT,AND WELL
CONSTRUCTION PERMITARE SUBJECT TO REVOCATION W 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,CONSTRUCRON AUTHORZATION(BOTH VALID FOR 60
MONTHS FROM DATE IMPROVEMENT PERMIT IS ISSUED).AND WELL PERMIT IF APPLICABLE BEFORE INSTALLING THE ABOVE SITE PLAN.
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