GW1-2023-01550_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only-
,1.R'ell Contractor Information:
Kyle C. Shaw I1.WATER ZONES
P. \iI TO I DESCRWTIOti
%Veil Contractor,lame n ` '
4521-A
FEB J 9 2023 if
NC Well Contractor Certification dumber L.OUTER CASING for multi cased wells OR LINER tf a lioble
Advanced Well Drilling, LLC °" TO ft D>x%6 in. THeavy AIATEPVC
Company Idamc
ff )) —21 1 16.INNER CASING OR TUBING r eothermal closed-loop)
2.1ireff Construction Permit#: E21_ ll f l��✓ l _ FROM To DL1,1fETER rutctwFss nL1TERIAL
List all applicable well construction permits(%G[17C.Coonn:State.!'arimue.etc)
ft. R. in.
3.Well Use(check well use): ft ft itL
Water Supply VVe0: 17.SCREEN
FROdt I TO D1A_ L7FR SLOT SIZE THiC6,'NFSS 1LATER aL
El Agricultural ❑\ftmicipal%Public ft. ft la
❑Geotlierm al(Heating/Cooling Supply) MResidential R%ater Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lineation ❑Wells>100.000 GPD FROM I TO MATERLAL E.NiPUCENILWT METHOD sv AMOIZT
Non-1ltater Supply Well: It. rt Bentonite Poured
❑.Monitorins! ❑Recovery• ft ft.
Infection 111eil: ft ft
❑Aquifer Recharge ❑Ground%mater Remediation
19.SAND/GROVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FRO\% TO \iATERIAL E.IPLACENrL%'T METHOD
❑Aquifer Test ❑Stormx%ater Drainage D. fL
❑Experimental Technology ❑Subsidence Control rL M
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION color,hardnesx solUmck tr e.Aram dw.etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under=21 Remarks) ^ ft —C ft
4 Date Well(s)Completed:Completed:l7_-�- R'ell IB# (� n B
Set.Well Location: n IL Ott`
a L 1 c ft -70
ft
Facility/Owner Name Facility•ID=(if applicable) `7 R D
ft cit
A,�F��r =" ! I �1#�� ft �ft
Physical Address,City,and Zip
Lt 21.REALARICS
County Parcel Identification No.TIN)
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification.
3�.,wl//2�i N Kl-7_:Z . 1 11 Z-
&Is(are)the wetl(s): MPerm=ent or GTemporary Sianan&of Certified ii•'ell Contractor Date
Bvsigning this faint,I herebt•cernf,that the isgUf"s)was(uvre)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or tiNo 134 A'CAC 02C.0100 or 15.1 NCAC 02C.0200)i ell Constr ction Srandards and that a cops-
If this is a repair,fill ow itnOW71 well construction information and explain the mature of the of this record has been provided to the well owvter.
repair underY21 remade section or on the back-of thiSform 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 ball constriction info
construction,only 1 GW`-1 is needed. Indicate TOTAL NKLINEBER of%%ells (add'See O ee in Remarks Box).You may also attach additional pages if necessm.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GR'-1 within 30 days of well completion per the following:
multiple wells list all dept s if different(example-3wa�300'and 2.a100')
10.Static water level below top of casing:�s(� (�) 24a• For all 11'ells: Original form to Division of Water Resources (DRR),
If motor level is above caring use"+" Information Processing Unii,1617 MSC,Raleigh,l\C 27699-1617
11.Borehole diameter. 6 (m) 24b.For Injection Wells:Copy to DWR.Underground Injection Control(IUC)
rr Proerain. 1636 MSC,Raleigh_NC 27699-1636
12.Well construction method:A 1 r^ va F 24c.For Water Supply and O n-Loo Geothermal Return Wells:Copy to the
(Le,eager,rotary,cable,direct push,etc.) county environmental health department of the county where costa led
FOR 11'ATER SI/TPLY 1YELLS ONLY: 24d.For Water Wells producing over 100 000 GPD:Copy to DWR,CCPCUA
13a.17eld(gpm) 2' Method of test: Air Permit Pnoeram,1611 NISC,ttaleizh,NC -1
611
13b.Disinfection type: HTH I Amount:
Noah Carolina Department of Emironmental Quality-Division of Water Resources Rmise`_•=-=_,!c

LINCOLN COUNTY HEALTH DEPARTMEN 71 _._��
1S West Main Stmet-UNCOL.NTON, N.C.28092-PHONE: [phone] -VALX: [phone]
Permit#: EHW21-05U7 Pa"I Id*. 81462
Owner. PATRIOT LANCE LLC Phone; [phone]
Address: 2442 GATEWAY LANE City: UNCCL14TON .State: NC Zip: 28092
Appikant; Phone:
Address: City: State; Zip.
Location HOFFMAN ACRES ST Sub: GEORGE T HOFFMAN FIEIRS Lott 8
WELL CONSTRUCTION PERM
7:5
ell
T iQ :7:2
LO
- � Aria
N DMTANC€METWEEN WATER SUPPLY ANO SEPTIC OR rain ON FEET)
DNDI ON-S
"Sure well is located 25ft min off all structural foundations and 50ft min off wastewater system to include any future
pair area,
/tiUTHOdti2W Brad Haltman REHS F'
AOEHT 8 DATE. &loa t
NU�R04'FJAE�1f PERMIT,11Lf1HQRIZAi1G1!Tp�OMBTRI T.An WELL C0%*TWCT10N PEAWt EACH T"IWACAMO 7 PEMWI JI M NOOWATION TO C4NS7RV Ci.AND VVMU,
+�1r ,tA�Cl�N PE}�Mft ARE 11i1$t6Ci TA GA7tdY 7fi 3fTE 1'UMIi OR 7FiL tNld10lD Uti ARY CNAMti®iTiOM 11100E d1lOWN LM Zb�sE PE3'M175, C!{A3fGr;+�Ffi�d TIC A�+'W!
s»t1SE R1F t41T.idA?{RikiN�N PIsL 1tEA1Tli APPRQY1LL. THE piSTALtMS*HALL EE REQU M TC NAVE AN I Y f,tA1�5 P tih T; N 7:�K G A t f;(8Q11i VW i47;k?it 5�
NIffNTlta FROM OA°PE WPRtV VW-NTPHRAff is mstlern.ANO WELL Pnmrr lfi�l�l}c#BLB BEft`Ri tNS744Ltll�a liti lP[kvE 53MI MUZ