GW1-2022-08317_Well Construction - GW1_20220517 (2)

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. ell Contractor Information:
Y"
q ` j 14:WATER'ZONES
I� 11� �
Well Itractor N me FROM TO DESCRIPTIONkqft. 2ft. C J
NC Well Contractor Certification Number
� 15:OUTER CASING for nrulli-cased wells OR LINER,(if a 1lcablc`.
14 1 I t��S i p'Q' ` �'/lt�! _ FROM TO DIAMETER TffiCKNESS MATERIAL
w `` y V(•, r �( —` ft. �Q ft. � in.
Company Name O V v
16.INNER CASING OR TUBING' eotherntal closed-loo
2.Well Construction Permit#: `d �j FROM TO DIAMETER TffiCKNESS 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 TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_;Agricultural E]Municipal/Public , ft. 21 ft. Z in. I C)I Le SLh IAO PV(—
Geothermal(Heating/Cooling Supply) �IResidential Water Supply(single) ft. ft. in.
Industrial/Commercial FnIResidential Water Supply(shared) 18.GROUT: ,
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1-7 ft. 4i \-0nAC _ 1
(-Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge (�Groundwater Remediation 19.SAND/GRAVEL PACK(if a' Iicable
Aquifer Storage and Recovery 0ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test MI Ston ft
nwater Drainage ` ft. Z1
NExperimental
. # Y
Technology FnISubsidence Control r�`
bGeothermal(Closed Loop) E]aracer 20.DRILLING LOG(attach additional shcets.if necess'ar'
FROM TO DESCRIPTION(color,hardness,soil/rock type,•rain size,etc.)
_�Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) O ft. I ft. `1
4.Date Well(s)Completed: 2D Well ID# ft. 0i ft. saindiA
5a.Well
Location: i ,- COft. ft. n
5% V' / _y-�GSA\A W- ft. ft.
Facility//O7wndN�l"a•ImeC�F/' - Facility ID#(if applicable) ft. ft.
2- l 1 �eAI ZA ft. ft.
Phy'c�al�A,d�d�reess,City,and Zip ft. ft.
�J�r�f\�U- oq(�l� ",5,f-q 21.REMARKS
County Parcel Identification No.(PIN) -� �,�' r• <>;i�l,�,i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Cer'fieation'
N �01159 W
6.Is(are)the well(s)iIPermanent or fOlTemporary Signature of Certifie ell Contractor Dat
"`ttt""" `, By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QIYes or r(.pNo with 15A NCAC 02C.0100 or 15A 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#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: n(` (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1f dierent(example-3+@r2�00'and 2@I00� construction to the following:
10.Static water level below top of casing: I (ft.) Division of Water Resources,Information Processing Unit,
If 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
AA above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: M%U 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) 1 Method of test:��_ 24c.For Water Supply&Infection Wells: In addition to sending the form to
i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: K1 Amount: l "l C 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 Resource's Revised 2-22-2016
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
Roy COOPER MANDY COHEN,MD,MPH
GOVERNOR SECRETARY
BETH LOVETr
ACTING DIRECTOR
Onsite Water Protection Branch
December 05,2019
Sandy Creek Land Co.
PO Box 616
Stedman,NC 28391
RE: Approval No.WWM959
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C.0116
512 Corbell Rd.
Stedman,NC 28391
To Whom it May Concern,
On December 05,2019,the On-site Water Protection Section received your request to approve construction of a well obtaining water
from a depth less than 20 feet in an area not covered by 15A NCAC 02C.0116(b). The approval request is for the construction of one
(1)water supply well at 512 Corbell Rd.,Stedman,NC. In your request,you indicated that due the inability to obtain potable water at
deeper depths,a shallow screened well was the most reasonable option at this property.
Based upon available information provided,you are approved to construct a well obtaining water from a depth less than 20 feet below
land surface,in conformity with the requirements of 15A NCAC 02C.0116(c)(3),that will serve the above referenced site. A copy of
this approval should be attached to the required Well Construction Record(GW-1)as well as the county well permit at such time that
it is issued. Furthermore,it is strongly recommended that you sample your well annually for bacteriological contamination,as
shallow wells can be more susceptible to bacteria.
The approval of this variance does not affect any of the other requirements or limitations of the Well Construction Standards,
including but not limited to the requirements in 15A NCAC 2C.0113(b)to repair or to abandon any well which acts as a source or
channel for the migration of contamination or to your responsibility to comply with any other applicable Federal, State,or local laws
or regulations.
The granting of this approval is for the well location only,and in no way relieves the owner or agent from other requirements of the
North Carolina Well Construction Standards,or any other applicable law,rule,or regulation that may be regulated by other agencies,
nor does it imply sufficient water quality.
If you have any questions regarding this variance,please contact Wilson Mize at(919) -270-9665
Sincerely,
Wilson Mize R.E.H.S.
WWW.NCDHHS.GOV
TEL [phone]•FAx [phone]
LOCATION:5605 Six FORKS RD•RALEIGH,NC 27609
MAILING ADDRESS: 1642 MAIL SERVICE CENTER•RALEIGH,NC 27699-1642
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