GW1-2022-08369_Well Construction - GW1_20220517

;. WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: T
t,�r'v1 ,1� k � V y 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a 6cable)
1��t'��,�@`� �1�� FROM TO DIAMETER THICKNESS MATERIAL
`
y V D�� y V V ` +1 ft. I J ft. I LJ in. SLb q 0 Pvc-
Company Name
�- e ���D 16.INNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#: �-}l FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic tLAft. IS ft. in. d aSCVl40 PV-
❑Geothermal(Heating/Cooling Supply) *sidential Water Supply(single) ft. ft. in. t
❑lndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. - 0% .
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 1 ft. ft. 2
❑Experimental Technology El Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,eta)
p D IL ft. 1,9 5 r
4.Date Well(s)Completed: l' - Well ID# ft. ft. n� G a
5a.Well Location:
t1 ft. ft. 4-vt n G`u
--V-ILa'== IW M y
ft. l ft. G n SfilY�
Facility/Owner
Name nn 11 /� �,,�F�aciilittyy IDD(#(if applicable) Cl ft. ��� ft. 4
3 1Q-1 \IA Cam\ f'y"1 u C�I/lt r-n 1 gk'
Physical Address,City,and Zip ft. ft.
21.REMARKS
�°,��,,y�nh.efwLh . n 3 SSb 5 � I l8 s
County Parcel Identification No.(PIN) I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
rlUq N i �-1 1t1� w ��� tA/ -�
6.Is(are)the well(s): (�ermanent or ❑Temporary Signature of Ce ed Well Contra for Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information add explain the nature of the 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 construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: °�� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: OSJ (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@7000
24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1_i l � 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
5 V r'�P Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: Y
13b.Disinfection type: t `-T`A Amount: 1/7,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
ROY COOPER MANDY COBEN,MD,MPH
GOVERNOR SECRETARY
MARK BENTON
DIRECTOR
Onsite Water Protection Branch
November 2,2021
Adam&Julie Robertson
3909 Rebel Rd.
Linden,NC 28356
RE:Approval No.1282
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C.0116
3909 Rebel Rd.,Linden,NC
Dear Mr.&Mrs.Robertson,
On November 2,2021,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 3909 Rebel Rd.,Linden,NC. In your request,you indicated that due the inability to obtain potable water at
deeper depths,a shallow screened well was the most appropriate 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.
The well shall be sampled for bacteria and inorganics upon completion. Should the sample results indicate the presence of bacteria,
treatment of the well may be required. 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(9.19)-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
AN EQUAL OPPORTUNrrY/AFFIRMATIVE ACTION EMPLOYER