GW1-2022-03154_Well Construction - GW1_20220222

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1.Well Contractor Information:
Tarrell Benford Graham Jr. ,14i'WATERZONES
Well Contractor Name FROM TO I DESCRIPTION
NCWC 2373-A 312 ft- 313 ft. Cracklin Rock
519 ft• 520 rr.
Crack;In Rock
NC Well Contractor Certification Number 45 OUTER=:CASING:for mulfi-aas I wells;=0RJANER-ifa Iicable
Graham Currie Diversified Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 183 ft. 14.6 in. SDR 17 PVC
3398(,� '16:'1NNER CASING,0R'TUBING;(.eothermalrclosed.loo
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2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e, U/C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 11 SCREEN'
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
3. 1ndustrial/Commercial OResidential Water Supply(shared)
186�
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 23 ft• Hole Plug Poured
i Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
I4:SANDlG12`AYEL P:ACK..it"?a '1iea61e;
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach:additional:sheets:if-necessa
Geothermal(Heating/Cooling Return) rtOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0 ft. 25 ft. yellow/orange sand
4.Date Well(s)Completed: 12/14/2021 Well ID# 25 ft. 69 ft• hard grey/brown clay
5a.Well Location: 69 ft. 93 ft' hard grey clay
Craig French 93 ft. 119 ft. grey/brown sandy clay
Facility/Owner Name Facility ID#(ifapplicable) 119 ft. 152 f` hard grey clay
363 Summer Creek Trail, Vass NC, 28394 152 ft' 171 ft- grey slate rock
Physical Address,City,and Zip 171 ft- 565 ft. grey IA
Moore 20010463 21;'REMARKS ' 'qq`
County Parcel Identification No.(PIN) FEB [qqnn UG?
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Certification:
3 t St7�i N O U1
6.Is(are)the well(s)(x Permanent or E)Temporary ore of Cell ract Date +
By signing this form, rere y certify that the well(s)was re)constructed in accordance
7.1s this a repair to an existing well: LDYes orgNo with ISA NCAC 01C.0I00 or ISA NCAC 01C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe 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: 565 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierenl(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 142 (ft,) Division of Water Resources,Information Processing Unit,
/frvalerlevel is above casing,use^+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:4•5 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
Mud Rota and Air above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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 Servic' Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 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: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

Permit# 33986 PID or LRK4 20010463 Page 1 of 2
Property Address 363 Summer Creek Trail Vass,NC i Number of Bedrooms
Moore County Health Departmlent
Environmental Health Section i
0�} 1704 P.O. Box 279,Carthage,NC 28327
Phone:910-947=6283 Fax:.[phone]
°FNOfifH�t�
Well Permit
Applicant Name: Craig Thomas French
Applicant Address: same as above
Phone: [phone] Email:
Property Address: 363 Summer Creek Trail Vass, NC
Type of Well: Private X Irrigation:
Geothermal :Agriculture:
Number of Persons to be Served: 4 Number of Con ections: 3
Date: 4/22/2021 Env. Specialist:
*Well shall be installed as shown on permit. Well permit is vaff' for five ye s from date of issue.
Notification must be given to Environmental Health when well becomes operational so that water
samples can be taken.
Well Setbacks _
50' minimum from any septic system
* 25' minimum from any foundation
* 50' minimum from any source of contamination
* 100' minimum from any barn, chicken house, dry stack area, etc,
Well construction record provided to: Health Dept. Owner
I certify that the well constructed on the above property meets all requirements of 15A NCAC 2C Well
Construction Standards. '.a-o V-
Well Contractor: Phone 4146
Signed: "" Date:
Grout Inspection By: 'r Date:
Well Head Inspected By: "� Date:
Bacterial Water Analysis.Report: Date Taken: Date Received:
Inorganic Water Analysis Report: Date Taken: Date Received:
Nitrate/Nitrite Water Analysis Report: Date Taken: Date Received:
Certificate of Completion: Date:
MCEHD July 2020
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County of Moore ! '
Vepartment of Ja eaath
705 Pinehurst Avenue• P.O. Box 279
Carthage, North Carotin 28327
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Telephone: [phone]
Robert R.•Wittmann, M.P.H. Medical Records Fax: [phone]
Director Administration Fax: [phone]
Designation of Legal Representative
Mowery-Family Trust, Joseph M Mowery, Alison S Linn-Mowery, Trustees
hereby authorize
Property Owner(print)
to serve as my legal
Legal Representative (print)
representative for the purpose of obtaining a permit to install, repair or expand
an on-site wastewater system and/or well. I understand that submittal of the
application for evaluation will authorize the Moore County Health Department to
perform said evaluation on my property.
Address of Property: 363 summer Creek Trail , Vass NC 28394
LRK # 20010463 Lot 7
DocuS/igned by: cuSlgned by:
$ignat r�O L k khw FZ6VU IAIn,r�(bbU Date 3/12/2021 1 7:54 AM PST
BC60E39392A487... Prope '�cpR39ag487...
Signature Date
Legal Representative
"To Protect and Promote Health through Prevention and Control of Disease and Injury."
http://w,ww.moorecountyno.gov/health/ j
Environmental Health WIC
Telephone: [phone] Telephone: [phone]
Fax: [phone] Appointments: 910-947-3271
Fax: 910-947"2460
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