__20220311 (52)

vvr.LL l,V113111 U1.11V1V liLl,Vlill Ill W-1) For Internal Use Only:
1.Well Contractor Information:
Tarrell Benford Graham Jr. 14.WATEWZONES
Well Contractor Name FROM TO DESCRIPTION
NCWC 2373-A 50 it• 78 ft• yellow sand streak of clay
ft, ft.
NC Well Contractor Certification Number 15.OUTER"C 1SIN.GIfor multkeased'well)'OR LINER:(ilap'Iicaltle) `
Graham Currie Diversified Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
ft ft. i in.
Company Name
16.INNER CASING.OR TUBING=(geothermal cl'osedloop)
2.Well Construction Permit#:476 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1.7;SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
$,Agricultural Municipal/Public 55 ft. 65 ft. 4 in. 30 sch 40 PVC
*Geothermal(Heating/Cooling Supply) DIResidential Water Supply(single) 65 ft. 70 it 4 '" 30 sch 40 Stainless
MI Industrial/Commercial DResidential Water Supply(shared) IS.GROUT.'
.....1Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
*Monitoring DRecovery ft. ft.
i
Injection Well: ft. ft.
*Aquifer Recharge DGroundwater Remediation
19::SAND/GRAVEL:PACK.(if applicable)
*Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
"[Aquifer Test Stormwater Drainage 25 ft. 75 it. #3 Sand Poured
$tExperimental Technology ;pSubsidence Control ft. ft.
(*Geothermal(Closed Loop) OTracer 20:'DRILLINGiOG'(attach additionahsheetsbifneeessary)
Geothermal(Heating/Cooling Return) *Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft. 8 ft. yellow sand
4.Date Well(s)Completed:9/30/2021 Well ID# 8 ft. 22 it• grey clay
5a.Well Location: 22 ft. 68 ft' yellow sand streak clay
Vasile Tavoc 68 ft. 75 ft. grey clay
Facility/Owner Name Facility ID#(if applicable) ft. ft. TT.'
;- i-
227 Sonee Lane , Aberdeen NC, 28315. . ft. ft. .
Physical Address,City,and Zip ft. ft. MAR 1 # 2029
Hoke 21.'REMARKS
1, r•:1 -.,. ;
County Parcel Identification No.(PIN)
a i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 ion:
:.j,5r03' v1 N 75. .2,6 "wLe W / .
/0/a ..7_,/
6.Is(are)the well(s) Permanent or Temporary Signature of Certi I o ctor Date
t'— By signing mm7orm,thereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or DNo with 15A NCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a
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 112l 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: 75 (ft.) 24a. For All Wells: Submit;this form within 30 days of completion of well
For 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: 171 //3 4 L (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:7.75 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
Mud and Rotaryabove, also submit one copy
df this form within 30 days of completion of well
12.Well construction method: 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 Serviee Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply& Injection 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

i
476 .
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0 �,`� ;gam 683 East Palmer Street �\sci'}-0'`"t �x y
S Raeford,North Carolina 28376 `' `-^ate
Helene Edwards.MS,RD, LDN [phone]
Health Director FAX[phone]
Well Construction Permit
Owner: Vasile Tavoc
Location of Well: .._.. 227 Sonee Lane.., Aberdeen, NC 283'15
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I---- _........_..__ .-...._........._ _ __ ...... _ ..___ ..._ .......... _ — —..........._..— _ `--- —
(Site sketch) r ( ,,
Additional Remarks:
Maintain 50' separation _lt_oM any sewage disposal s 'Stem I'
_.. Maintain 25- se atation from any_building foundation
Maintain 50' separation from any otlter_potential source of contamination
Type pe of well:
II Private drinking water well. ,
i
❑ Transient non-community water system
El Other �.__..__
Authorized State Aertt:• """J^ [:)ate. ' .fi "
This permit is valid for 5 years from the clay of issuance. The permit may not be altered wiihout written permission from a
representative of the Hoke County Health Department. The permit is subject to revocatiomjif there is a material change in any
fact or circumstance upon which the permit is issued. -,The permit is not affected by a change ofornrnership at't.he site.

au �,yua m,
°- • N r, HOKE COUNTY 6 i
12,14 Department of Public Health Ir
683 East Palmer Street 42
Raeford,North Carolina 28376
Helene Edwards,MS,RD,LDN (9.10)875-3717
Health Director FAX[phone]
ATTENTION
Now that you have been issued a Well Construction Permit, you may hire a
Certified Well Driller to install the well in its approved location. Once the well
driller has set the casing, it is their responsibility to contact this office to set up a
grouting inspection.
After the pump has been installed and there is power
(temporary/generator/permanent)to the well, it is THE OWNER'S
RESPONSIBILITY to notify this office so that we can pro\ide the final wellhead
inspection. It is during th.e final wellhead inspection that water samples will be
obtained.
No person shall place a private drinking water well into service without having
completed these steps. Emergency exceptions may be granted.
Water Samples can only be taken on Mondays, Tuesdays, and Wednesdays to
ensure proper delivery to the State Lab. The cost for these water samples were
included in the price of the permit.
Grouting inspections and wellhead inspections can. be requested during our office
hours Mon-Fri 8am — 5pm.
Please call one of the following numbers to set up an inspection date/time:
910-878-1270
910-878-1272
91.0-878-1273