GW1-2022-10694_Well Construction - GW1_20221205

WILL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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6e n ptI rd /�.r0L Pl 1� �i I FROM TO DESCRIPTION'
Well Contractor Name (± e� ft. ft,
3 7 C "fr Q `'" ft. ft,
NC Well ContractorCertification.Number v0 =;7`5?. .Il I1F)Tt,:CASfI C or iiiiilH drise11I+Ye11�=0in LINER:Ifaa l'nule y-_
FROM TO DIAMETER THICKNESS MATERIAL
lT r0� (�G v�r Well Dr;Il r a Cc� ft. fr, in,
Company Name fi11i T:NDTG'GSASIN'xOIifl1UBING= d"thenninlidloscd-loop'
`l01 l to 1 FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit N.. / oG 10 v' ft ft. l"
List all applicable+vell contraction penults p,e.UIC,County,Slate,parlance,etc.)
• rt. rr. in,
3.Well Use(check well use):
Water Supply Well. FROM TO DTAMETER SLO'Psl'/.F. THICKNESS MATERIAL
Agricultural E3Municipal/Public 'Q ft. ft It1.
Geothermal(Heating/Cooling Supply) ofZesidential Water Supply(single) ft. ft. 1n
Industrial/Commercial DResidential Water Supply(shared) I8 GROUT "i. ;j ?'•:':. '
FROM TO h1ATERlAL! EMPLACEMENTMETHOD&AMOUNT
irrigation
Non-Water Supply Well:
Monitoring R ft.
ecovery
Injection Well: ft ft
Aquifer Recharge I..i Groundwater Remediation f9iSANDY:bIIAYEL PAEK;.if ii illltoii6lb)' ` 00
Aquifer Storage and Recovery i.I SalinityBarrier FROM To MATERIAL P,'CEI E TMET. OD
StormwaterDrainage
:.)Aquifer Test � - - --•
:]Experimental Technology DSubsidence Control ft ft.
Geothermal(Closed Loop) Tracer ,:2o.Ti'RIULtNG;LO'G alEtr6h gift iNoiii'iu'shccts;if neccssnry)
FROM 0 DESCRIPTION(color•hmdness soilA•ock lync grain size,etc.)
rill Geothermal(Heating/Cooling Return) rjjOther(explain under#21 Remarks) ft,
4.Date Well(s)Completed:10 9 QQAVCII ID#
ft.
So.Well Location: - a ft. L
pa l ph Gaefc� _ ft' —
Facility/O+vnerName Facility ID#(ifepplicable) 3 ft. V� ft. p�V pV
p rt � 5 � t�G � .� G G0.�
o? ?5 �r A.lta 1� t�buwfa ?ws lug fr.
1 L ft. t<_
Physical Address,City,and Zip
County Parcel Identification No.(PIN)
5b,Latitude and longitude In degrees/mintites/seconds or decimal degrees: \
(ifwcll field,one lat/long is sufficient) Certlfleatlon:
3 S-. d o'1 o d N `l a°I
Isla ee i Date
6.Is(nre)the well(s) ermanent or I Temporary
- Wing Oils form,1 hereby certl lint the u•e//(s)tuns(u ere)caisu•ucted in accordance
7.Is this a repair to all existing well: [3Yes ors t No +l'Uh/ 2C.0100 or 15 CAC 02C.0200 liven urit•ucdon Standards and drat a
Jjlhls is a repair,fill out known u-ell construction htforniatio n and explain the nature of the copy of tills record has cea provided to the bell olvnen
repair under 921 remarks section or on the back ofth/s foray 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: oft•) 24n. Tor All Wells: Submit this forin within 30 days of completion of well
For nudliple wells list all depths rfdyjerent(example-3©200'and 2©1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,1111'01.111at1o11Pvocessing Unit,
Ij+vaier 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
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,rotaty,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Ser•vlce Ccuter,Raleigh,NC 27699-1636
13a,Yield(gpm) Method of test: 24c,For Water Supnly&Ini ection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction Ito the county health department of the county
13b.Disinfection type' Amount:
where constructed.
Form OW-1 North Carolina Department ofEnviranmental Quality-Division of Water Resources
Revised 2-22.2016

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Permit 0 L/ ` L- PID or I.RKIt 5 fry i Page 1 of 2 _
Property Address �` � 2• 1�✓�tr. 1�jZ . Number of Bedrooms
nx Moore County Health Department
Environmental Health Section
P.O. Box 279 Carthage, NC 28327
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Phone: [phone] Fax:[phone]'
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Well Permit
Applicant Narne: P�ALPH Ciri£i)'/ I —
Applicant Address: � 0 (V,4 t_
Phone: ���r, ,2. .,2(�y_3 Email:____.
Property Address:
Type of Well: Private Irrigation:
Geothermal Agriculture:
Number of Persons to be Served: Number of Connections:
Date: f^, Z �_ . Env. Specialist:
Well shall be Installed as shown on permit. Well permit is valid forfive yearslfrorn date of issue.
Notification must be given to Environmental Health when well becomes operail nal 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' minirnum 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 requirementsof 15A NCAC 2C Well
Construction Standards. +
Well Contractor: Phone!#
Signed: Date:
Grout Inspection By: Date:
Well Head Inspected By: Date:
Bacterial Water Analysis Report: Date Taken: Date Received:
Inorganic Water Analysis Report: Date Taken: i Date Received:
Nitrate/Nitrite Water Analysis Report: Date Taken: ' Date Received:
Certificate of Completion: f� Date:
MCEHD July 2020
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U-bunty oj-"Noore
17T4 Deyart-me-rit of 5leaCK
705`Pi WfiUPTt-5=1W?1118 9 T.O. BOX 27g
Carthage, .Nardi. CccroClml-28327
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