GW1-2021-07798_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.llrell Contractor Information:
Kyle C. Shaw 1a.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4521-A It ` It �1
INC Well Contractor Certification Number
b n li n ;ram
Advanced Well Drilling, LLC El-`�OUTER c10 formD��s Ell oTM� ra upmTERIAL
v Company Name ft n 6 ' in. Hea PVC vy
jj /�aa// ��,�c��,�,__ n 16.INNER CASING OR TUBIIiG eothermal closed400
2.Well Construction Permit#: 1 J-1 "2CitXl/"�"q 7 5.� FRO.It TO DIAMETER THICENM MATERIAL
List all applicable xeil construction permits(i.e.G7C,Couture state,Variance,eta) n fL is
3.Well Use(check well use): ft n in.
Water Supply Well: 17.SCREEN
FROM TO DfA11fETER FSLOTSIZE THICIu'NM I NUTEFUAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(HeatinJCooling Supply) In Residential Water Supply(single) ft n in.
❑lndustrial/Commereial ❑Residential Water Supply(shared) 18.GROUT
i❑�offrril t ial on ❑Wells>100.000GPD FROM TO MATERIAL E\PLACEf1TT METHOD&L\ObA
n-Water Supply Well: D n n Bentonite POUred
❑Monitoring ❑Recovery ft. fL
Injection Well:
❑Aquifer Recharge ❑Groundnmmter Remediation ft. n
19.SAND/GRAVEL PACK d'a licable
❑Aquifer Storage and Recovery ❑Salinity Bafrier FROM To I MATERIAL I EMPIACEMLNT 1fETHOD
❑Aquifer Test ❑Stornmater Drainage n
❑Experimental Technology ❑Subsidence Control n n
❑Geotimemmal(Closed Loop) ❑Tracer 20.DRILLLKG LOG hittach additional sheets if necesso
❑Geothermal(Heating/Cooling Return) ❑Otter(e. lain under#21 Remarks) I
FROM To DESCRIPTIov(color,hardness,soWrocktype,0-4n mre,err-)
t
ON
n ,<;* fL Si
4.Date Well(s)Completed: ((2 Well IDAt Q n Q, fL
a1.Well Location: e-4 ft n c j �
110 n i 'L n L cz
F�Iaci l(i jt s/Ow�ner NameFacility
Facilih-JD�=9(1t f/aPVP�lica ble) )))" R 13 o n
n
�1•
fL
a
I �t� c L
Physical Address,City,and Zip J-• ft. t ? ft. �p
g¢ 1 -2 Kz ' n
21.REMARKS CEL.
County Parcel Identification No.(PIN)
03
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: rt, but
(ifwell field one lattlong is sufficient)
22.Certification:
6.iS(ate)the well(s): OPermanent or ❑Temporary Stgnanife of Certified Well Contractor Date
Br signing this,form,l hereby certify that the uell(s)eras(were)constnrcted in accordance with
7.Is this a repair to an eidsting well: 011'es or &No 1 SA N'CAC 02C.0100 or 1 SA 1dC4C 02C.0200 Well Constnrction Standards and that a copy
Ifdds is a repair,,hll out known well constnrcfron information and explain the stature o{the oftlns record has been provided to the well ouwer,
repair under#21 remmia section or on the back-ofdris form
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having tie same You may use the back of this page to provide additional\\ell construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NTLAI 1BER of malls (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBINUTTAL LNSTRUCTIONS
9.Total well depth below land surface: ('1 ft.)
For nrtrltiple wells list all depths if Offerent(example-3@200'and 2Cif 001) Submit this Gllr 1 within 30 days of well completion per the following:
10.Static water level below top of casing- 410 (ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
Iftsuter level is above casing,use-+" ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole dinnerter.- 6 Cm,) 24b.For Iniection Wells: Copy to DWR,Underground Injection Control(IUC)
r
Program,1636 N4SC,Raleigh,NC 27699-1636
Le-llrell rotary.cable,
direct
1 r Q�tl 9.tt^.., 24c.For Water Supply and Open-Loop Geothermal Return Wells:Co to the
(i a auger,rotary,cable direct push etc.) county environmental health department of the county where installed Copy
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DU R,CCPCUA
13a.Yield(gpm) D3ethod of test: Air Pemmt rogram, 1611 N SC,Meigh,NIC 27699-1611
13b.Disinfection type: HTH Amount' t (M
North Carolina Department of Environmental Quality--Division of Water Resources
Revised 6-6-211jI F

CATAWBA COUNTY Case N WELL-10-2020-139732
Public Health Dgxutment Subdivision WSER COMMONS
Environmental Health Division 461704623673
PO Box 389,25 Government Drive,Newton,NC 28658 LOTA 18
r (828)465.U70 FAX[phone] TDD(828)465MOD LOT `
Site Address: 8628 IOSER COMMONS DR,TERRELL NC 28682
Name on Permit GM ALL AMERICAN SERVICES,LLC
PropertyStae: Acres 0.46
Directions: 150 to Kiser Island Rd right on Kiser Commons Dive 2nd lot on the right
MEW WELL PERMIT
REQUIRED WELL SETBACKS:
Septic Systems and Repair Areas for Single Family Dwellings 50 It
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%
Streams/BrookslCfeeks/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 I SA 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 well.
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 Weser Welt Testing(r SA NCAC 18A.38001 The fee for this sampling is included in the cost of the well permit.It is the applicant or
property owner'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 contact Environmental Health
�
10109/2020
Audxwized State Agent Permit Issuance Date
10/9/2025 .
PeradtExpvatiwt Date
ehpcnnit l(VI212020 16:50

' �' �
� .00 DON ALLEN & ASSOCIATES , 1?. A
D 'Slow 1071'
t Commarciai • Realdentla} • Mort�pe Surrey• Multi—F1am�Ay (� ` / QiJQV
�-t AA Construction Staking • SuWAS en Dastpn T & . Ne'
r 131 Croedake Park oiKv - Suite 102 •tlooresvme ' NC • 28tt�
(704) 66+-7029 (104) e64-8041 Fox
this mop was drawn under my supervision from an actual
s made under my supervision recorded In deed book 3413 — pages J and/o
plot boob..., e2 — page 105 that the
urvey I, certify that ratio of precision is 1':10,000. that this m
was prepared in accordance with the General Statutes of North Carolina Chapter 89C. i
my hand and seal on the 16 day of SEPTE►1PER
A.D. 20?0 1 (/ i
siaeaus �f•'t�Sf�!y.,.'!y= Qc,�/`''
PARCEL ID: 461704620969
��y;;1AA(��M��? •••
RECENCY PROPERTY
`°a4►s INVESTMENTS LLC.
3445/1269
1{/o%e3 W
95 28'
LOT 17 LOT 19
ROBERT A. KLATT .ran DEBRA L. STEELE
3025/0104 4 2387/0451
so
TREE YAMS
U MEE#1 TREE iTP
2. p ,� s. 1
1 e _ 30
♦, 31 a
3A PIPE ^ s 32 a e"
a 0" Tx �� 33 •
s PINE 5.6 of 41 S 34 FINE aler
JA
a 75am
FRK a.
a" 32 10.21
3a a
p PM 9 O! _ 2a0 11 PAT10at PoeE U . PRE i1a *. LOT f81s ~ 0.46 AC.) 1sT +� as Part ab
1 aS
21.0 N 3��/J N,t f+ . ae 011R 24•
1e 3 f( I® g ,o 9.
1 PI CNlAf.E �✓lj I S} ae •e
e 40 1a
21 PINE a P'ORH1 14 SO
x2 auc 1as ».; 2 s1 oac 1e-
2] O f, .• 52 OAK 1
• am I e �o -.C�IC.♦ • SE Ayl V
Qa%
7.e '( OaK 30.a
y►at1 a.:�. dVI
se 1!e • it w�� .x
ript
S65iZ30-E �= b12 R
1
95.29' (DES •W
IQSER COMMONS DRIVE
1 (46• R/W) e
ueo+a
W.P.-CASTM eiaN ram mom
SCALE IN FEET 1) 11e8 PBOPENnY MAY BE
R/f-Rio>lr-a-+.ur M eur Ens,21M rws
®. 80t1NDARY ,Qj Pu1NSURVEY mom It�
CF a NO 00 1,40EeeR11T� VM
8628 KISER COMMONS DRIVE xe0o PEE*•
T 18 KISER COMMONS DR.
O
SCALE 1 40- MOUNTAIN CREEK TWSP.. CATAWBA CO.. N.C. r IMM aori.o+s to
TA
ACQUIRED BY; MARVIN Wlt.l.lAMS TAX NO: 4617NO2 43