GW1-2021-02668_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.AVell Contractor Information:
Kyle C. Shaw ® 14.AVATERZONES
Well Contractor Name FROMI TO DESCRD'TION
�l
t
4521-A �9 IL I) 'L k
NC Well Contractor Certification Number U� 15-OUTER CASING for mtdti-cn is OR LIMIER f n licable
Advanced Well Drilling, LLC pro �s1n9 -FRONT TO DLAMIErER° rmCIx--Q MATERIAL
(Sa3-��g off_ ft % g ln. Heavy PVC
Company Name 16.INNER CASING OR TUBING eoUtermnl closed-lao
2.Nell Construction Permit#: LU-rJLJ- A aLD-'3 153 FRONT TO DIA)fETER in THICI�ESS \fATERLIL
List all applicable well construction permits(i.e.UIC.Comet-,State.I'ariance,etc) ft TO
rL fL in.
3.Nell Use(check well use):
AVater Supply i ell: 17.SCREEN
FROM I TO IDLAMfElER SLOT SIZE TRICKINESS MLATGRiAL
❑:Agricultural ❑-N-4unicipal/Public ft rL is
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) R, fL in
❑Industrial/Cotnitercial ❑Residential Water Supply(shared) Is.GROUT
❑Irrigation ❑Wells>100.000GPD FRONT TO MATERIAL EMPLACEMENTMETHOD&A1MOCIT
Non-Rater Supply Well: D rt ft Bentonite Poured
❑NIonitorine ❑Recovery ft %
Injection Nell: M fL
❑Aquifer Recharge ❑Groundwater Remediation
19.S4NDlGRAVELPACE:(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier ITO MATERIAL ENTPLACEMrEVT MIETHOD
❑Aquifer Test ❑StorruNwer Drainage fL fL
❑Experimental Technology ❑Subsidence Control ft. tt
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Heating/Cooling Return) ❑Other(explain under `21 Remarks) FROM To DFseItrnTl + (color.hardness soiutvck e,grain ilze,etc.)
4,Date Nell(s)Completed: Retl IIJI p c 1 fL
5a.R'ell Location: ft It &y4 V-D,- -
a2z 6-Cl 66A,16I� n fL IL
FacilitylOwner Name Facility ID=(if applicable) fL ft 7wre C
l a�� Llrs ac Jell �.�nnk R. boy,�C r o1Sr/n 4 ft 11 o f�acG c1C
Physical Address,City,and Zip
21.RElA3ARKS
County Parcel Identification No.(PIN) - �DS
Sb.Latitude and longitude in degrees/mjnutes/seconds or decimal degrees:
(if well field,one , q `,^fit]at/long is sufficient) C 22.Certification:
6.Is(are)the well(s): InPermanent or ❑Temporary S7gnat06ofCcrtified Well Contractor Date
h3,signing this form,I hereby verb,that the i+ell(s)was(were)constricted in accordance with
7.Is this a repair to an existing well: ❑Yes or ENo l5A NC4C 02C.0100 or 15A NCAC 02C.0200 Well Constniction Standards and that a crolm
If this is a repair,gill out known ivell constniction information and Explain the nature of the of tins record has been proilded to the hell owner.
repair Corder r21 renrarls section or on the back ofthis corm. 23.Site diagram Or additional well details-
8.For Geoprobe/DPT or Closed-Loop Geothermal Hells 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.\t+I-IBER of Nvells (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: a (fL) Submit this G\V-1 within 30 days of well completion per the following:
For multiple"lls list all depths if different(example-3(a200'and 2@100')
a 24a. For AD Hells: Original fdmh to Division of Water Resources (DVi12),
10.Static water level below top of casing:_t< (ft) Information Processing unit,1617�MSC,Raleigh,NC 27699-1617
If ituter level is abot e casing,use—"
24b. For Injection Wells: Copy to DWR;Underground Injection Control(IUC)
I1.Borehole diameter: ,,y6 Cam) Program,1636 AiSC,Raleigh,NC 27699-1636
12.AVell construction method: /b,e----q-a' E___t 24c.For AVater Supply and Open-Loop Geothermal Return Hells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR HATER SUPPLY WELLS ONLY: 24d.For AVater AVells producirLd over 100,000 GPD:Copy to DWR,CCPCUA
Air Permit Program 1611 I SC,Ralei NC 27699-1611
13a.Yield(gpm) Method of test:
HTH Amount•. 1k
13b.Disinfection type:
Form GW-I North Carolina Department of Emironmental Qualit♦•-Division of Water Resources Revised 6-0 201 c

CATAWBACOUM CAN WELL-04-2020-131538
Public Health Department Subdivision
Environmental Health Division PINK 470003201237
PO Box 389,25 Government Drive,Newton.NC 28658 LOT# 1
a
Site Address: 1297 HOPEWELL CHURCH RD, CATAWBA NC 28609
Name on Permit: BRETT&ALEXIS THOMPSON
Property Size: Acres 10.48
Directions: Sherrills Ford Rd,tum on Hopewell Church Rd,approx 1.5 from intersection
WELL PERMIT
WATER SUPPLY: Individual Well
REQUIRED SETBACKS:
Existing&Proposed Septic Systems 100 ft. Lakes/Ponds 50 ft.
Existing&Proposed Septic Repair Areas 100 ft. Streams/Brooks/Creeks/Rivers 25 ft.
Underground Storage Tanks 100 ft. Building Foundations 25 ft.
Animal Barns 100 ft. All Other Sources of
Groundwater Contamination 100 ft.
For a water supply well on a lot serving a single-family dwelling and intended for domestic use,where lot size
or other fixed conditions preclude the separation distances specified,horizontal separation distances shall be the
maximum possible but in no case less than:
Existing&Proposed Septic Systems 50& *No other setbacks may be reduced.
Existing&Proposed Septic Repair Area 50 ft. •Saprolite Septic Systems/RepairAreas may
Animal Barns 50 ft. not be reduced.
Wells constructed less than 100 feet from Existing&Proposed Septic Systems,Existing&Proposed Septic
Repair Areas and/or Animal Barns MUST BE CASED FROM LAND SURFACE TO A DEPTH OFAT
LEAST 35 FEET.
Wells'shall be constructed in accordance with state regulations:
Article 15A 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 828465-8270,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 Water Well Testing(15A NCAC 18A.3800).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
04/23/2020
Authorized State Agent Permit Issuance Date
4/23/2025
Permit Expiration Date
,I
k
thpimnit 04/23/2020 13:15