GW1-2022-03276_Well Construction - GW1_20220314

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1.Well Contractor Information:
Tarrell Benford Graham Jr. 14:'1'BATER;ZONES
Well Contractor Name FROM TO DESCRIPTION
NCWC 2373-A 46 ft 60 Orarige sand
rt rt.
NC Well Contractor Certification Number 45 OUTER'CASING for°multi eased*ells:OR LINERr f a lie able
Graham Currie Diversified Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. rt. in.
Company Name I
3 C(1 . 16:^1NNER:CASING OR.T' BING„ eotherrual=closed-lo,
2.Well Construction Permit#: `J94 FROM TO I DIAMETER I 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.
17.`SCREEN
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNES I MATERIAL
Agricultural ( Municipal/Public 50 ft 55 ft 4 '"' 30 SCh 40 PVC
Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) 55 fr 60 ft 4 '"' 30 SCh 40 Stainless
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
F.Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery
lnjei:tion Well:
Aquifer Recharge DGroundwater Remediation
1&,SAND/GRAy.tLiPACk if,a i li'cable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 25 ft. 67 ft. #3 Sand Poured
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 0.DRILLING LOGS attach additionallsheetsiifnecessat ,
FROM TO DESCRIPTION color,hardness,soil/rock type, rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 tt. 18 ft. orange/grey clay
4.Date Well(s)Completed:9/29/21 Well ID# 18 rr. 29 ft. re. clay
5a.Well Location: 29 rt. 46 ft- oran a and grey clay
Boyce Dowd 46 ft 60 ft- orange sand
Facility/Owner Name Facility ID#(if applicable) 60 ft, 67 ft. grey clay
168 Brookside Drive, West End NC, 27376
Physical Address,City,and Zip ft. ft. i" "'T( ,(• I,'+.
Moore 00991498 21.REMARKS MAR 14
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if well field,one lat/long is sufficient) j /) 22.Certif c ' ; ' �,l(�,.N( ,. .t: � - �i'•"
3S�/3 ' 5��� N7tS 10 as
6.Is(are)the well(s)(x;Permanent or DTemporary Si gna t e ell'Contract Date
�,^�.� By signi in, here rtify that the well(,)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or E]No with A NCAC 02C.0100 or ISA 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 1121 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 I 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: 67 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100') construction to the following:
Static water level below top of casing:„�7 / (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Servic i e 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 Rotary above, also submit one copy of 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 Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 24c. For Water Supply&Initection 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-I North Carolina Department of Environmental Quality-Division or Water Resources Revised 2-22-2016

Permit# 35942 PID or LRK# 00991498 Page 1 of 2
Property Address 168Brookside Rd. I Number of Bedrooms 3
oak' Moore County Health Depertn��
�} Environmental Health Section
1�ed P.O. Box 279,Carthage,SIC 28327
Phone:[phone] Fax,910-947-5127
'�NQRM CP
Well Permit
Applicant Name: Boyce Dowd
Applicant Address: 168 Brookside Rd, West End, NC
Phone: [phone] Email:
Property Address: same
Type of Well: Private X Irrigation:
Geothermal Agriculture:
Number of Persons to be Served: 2 Number of Connections: 1
Date: 7/29/2021 Env.Specialist: �, �; (< t �. 2C w`r :)
* Well shall be installed as shown on permit, Well permit is valid or five years 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.
Well Contractor: Phone #
Signed: bate:
Grout inspection By: Date:
Well Head Inspected By: Date:
Bacterial Water Analysis Report: Date Taken: Date Received:
i
Inorganic Water Analysis Report: Date Taken: Date Received:
Nitrate/Nitrite Water Analysis Report: Date Taken: Date Received:
Certificate of Completion: Date:
MCEHD July 2020

Byrn uy��
. County of indoore
Department o f 3fealt�C
7o5 Pinehurst Avenue s 'P.O. Box 279
Carthage, North CaroCina 28327
Owner: quo,.U. ,-belw A Page-3-of q
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Addendum to Receipt #: 3 Z3 aS 2
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