GW1-2022-02939_Well Construction - GW1_20220228

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t L L Lo U IVO I M U U I I U IV ri t la U tS U I U VV I I Por Intemal Use Oniy:
Well C ractor Infor n:
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Contract ame F�'5 ft.ROM I T 0 ft.O I-3 DESCRIPTION
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1 �C�ft ft. / y, J
We] Contractor Certification Number O� C as r c
15.OUTER CASING for multi cased wells OR LI R i a Iica6le
,•� A FROM TO DIAMETER THICKNESS MATERIAL
L[D�ty LIJL�t.L [�. 0
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 0 0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS I MATERIAL
Agricultural �=effl'ml
l/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irri ation FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. .� ft. L Rt� (.� TL Ou7
Monitoring Recovery ft. ft' S'A�
G kT -tN
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.D R I L L I N G LOG attach additional sheets if necessary)
RFROM TO DESCRIPTION color,hardness,soiUrock e, rainsize,etc.
Geothermal(Heating/CoolingReturn) - Other(explain under#21 Remarks) 0 ft. � ft.
4.Date Well(s)Completed.1— — Well I D# v ft. ft e
5a.Well Location: ft. ft.
6 �Tr
it. ft.
Facility/Owner Name /�/ // Facility ED#(if applicable) ft. ft.
AML.
Physical Address,City,and Zip / r ft. ft. ( �� 2
Co ���C7 9��y� 21.REMARKS Ud
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County Parcel Identification No.(PSI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. "erI" :
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6. Is(are)the wells) ermanent or Temporary signarur fcertifieawe Contractor Dale
,r By signing this form, l hereby certify that the"11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: M
Yes or 410 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and thata
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this 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 well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / 60r (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
far multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources, Information Processing Unit,
ff water level is above casing,use"_ 1617 Mail Service Center, Raleigh,NC 27699-1617
11.Borehole diameter: `/ (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
above. also submit one copy of this form within 30 days of completion of well
12.Well construction method:—0. N r construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: r 24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: N- Amount: L completion of well construction to the county health department of the county
where constructed.

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�r �'+ Environmental Health Division
P.O.Box 8181,131 West Margaret Lane,Suite 100
Hillsborough,NC 27278
Phone [phone] Fax [phone]
www.co.oranec.uc.us
WELL PERMIT
Pin: 9857692902 TMBL: 2
Application Date: 11/15/2018 Permit number: W18-00309
APPLICANT: OWENSBY KELLY K OWNER: OWENSBY KELLY K
ADDRESS: 2580 SHADETREE LN ADDRESS: 2580 SHADETREE LN
HILLSBOROUGH NC HILLSBOROUGH NC,
27278 27278
PHONE: [phone] / PHONE: [phone] /
EMAIL: [e-mail] EMAIL: [e-mail]
Property Desc: E AUBURN MEADOW P119/77 Lot Size: 6
Property Address: 832 AUBURN LN OCPL
Well Type: PRIVATE WELL WW System: On-Site System
NEW WELL
Comments/Conditions:
ISSUED: 12/07/2018 VLNS EXPIRES: 12/07/2023
ENVIRONMENTAL HEALTH SPECIALIST
PERMIT CONDITIONS:
* REFER TO THE ATTACHED SITE PLAN SHOWING THE WELL AND FACILITY LOCATIONS AND OTHER SPECIFICATIONS
* THIS PERIMIT MAY BECOME INVALID AND MAY BE REVOKED IF:
* The information submitted on the application is incorrect,falsified or changes,
* The site is altered,or
* The well is not completed before the expiration date.
* THE WELL SHALL BE CONSTRUCTED OR REPAIRED IN ACCORDANCE WITH:
Orange County Groundwater Protection Rules as adopted by the Orange County Board of Health.
NC Well Construction Standards,as applicable and
Orange County Environmental Health Division Policies
* THE WELL SITING IS BASED ON SETBACK DISTANCES FROM KNOWN FEATURES AND DOES NOT INDICATE NOR GUARANTEE THAT
ANY QUANTITY OR QUALITY OF WATER WILL BE PROVIDED BY A WELL CONSTRUCTED IN THAT AREA.
* The well must be located in well-drained areas that are not subject to flooding. Some of the setback distances include:
40 feet from any property line,
50 feet from any building founcdation;sewer line;swimming pool,pump room,or storage area;or storage building,
100 feet from A septic system or repair area or other potential source of contamination.
If it is not possible to achieve these distances,a reduced setback may be granted provided specific conditions arc met.
* Ground surface should be maintained to direct surface water away from the well.
* Setbacks for Public Water Supplies may be increased.
* All new or repaired wells must be4horoughly disinfected after construction.All traces of chlorine must be flushed out of the system at least 48 hours prior to
sampling.
* Water samples may be taken upon request by submitting a proper application and appropriate fees:the Orange County Health Department does not provide
water sampling for use as a condition of purchase,loan approval,or a property transaction.These services are provided by the private sector.
* Any changes to the proposed plans must be approved by the OCIID
* Wells must be constructed,repaired,and abandoned by a person who holds a valid certification from the State and who is also registered in Orange Count
for well construction.
* A list of registered well drillers is available upon request.
* The well construction must be inspected by OCHD at certain stages during the installation.
* The permitee is responsible for obtaining the appropriate permits for the wiring of pump installations from the Orange County Building Inspections Office.
* His the responsiblity of the well contractor to call the OCHD to schedule the installation inspections.
* After the installation is completed,some settling of the grout material may take place.If it has settled substantially,please call the well contractor to complete
the grouting-otherwise,the void can be filled with cement grout when a slab is poured.
* The owner is responsible for marking all property lines and corners.The Contractor is responsible for ensuring that the well or septic system is installed in
the proper location and that all setbacks are met.
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This map contains parcels prepared for the inventory of real property within Orange County,and is compiled from a Sz
W B recorded deeds,plats and other public records and data. Users of this map are hereby notified khat the aforementioned
public primary information sources should be consulted for verification of the information contained on this map. The
county and its mapping companies assume no legal responsibility for the information on this map. 'orb `sto"ee
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