WS0801045_Application_20200127

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER RESOURCES — AQUIFER PROTECTION SECTION
APPLICATION FOR PERMIT TO CONSTRUCT A WATER SUPPLY WELL OR WELL SYSTEM
(Wells or Well Systems with a Design Capacity of 100,000 Gallons Per Day or Greater)
PLEASE TYPE OR PRINT CLEARLY
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made for a permit to construct water supply wells.
1. Dale:
1 /20/2020
2. County: Pender
3. Applicant Rooks Farm Service
FOR OFFICE USE ONLY
PERMIT NO, 0046016VT ISSUED DATE: 1 E7 0
Telephone: [phone]
Applicant's Mailing Address: 301 North Dudley Street, Burgaw, NC 28425
Applicant's Email Address (if available): jeffrerooks@gmail. corn
4. Contact Person (if different than Applicant): Jeff Rooks
Contact Person's Mailing Address: Same as above
Contac Person's Email Address (if available):
5. Property Owner (if different than Applicant): Same
Owner's Mailing Address:
Telephone: [phone]
Telephone:
Owner's Email Address (if available):
ern r
6. Property Physical Address (including zip code) and PIN Number: 715 Loa
d,. ad, Burgaw, NC 28425
'' 3208 y6 y066 0000
7. Intended use of Well or Well System: Irrigation
(examples: irrigation, consumption, etc.)
8. Will the proposed water supply well or well system replace or be added to an existing well or well system? No
(If yes, complete questions 7 and 8) (If no, complete question 7 and then skip to question 9)
9. Total design capacity of proposed well or well system in gallons per day (gpd): 288,000
10. If adding a well to an existing system, list the existing water supply wells in the existing system and tlkno"ieldciDWR
JAN 2 4 2020
11. Is this a public well or well system? No If yes, give Public Water ID Number:
If yes, give Project Engineer and contact information: uE
12. Well Contractor: William Jefferys Well Contractor Certification No.: 2409
Well Contractor Address: 354 Sawdust Road, Rocky Point, NC 28457
PROPOSED WELL CONSTRUCTION INFORMATION
As required by 15A NCAC 02C .0105(f)(7), attach a well
construction diagram of each well showing the following:
a. Borehole and well diameter
b. Estimated well depth
C. Screen intervals
d. Sand/gravel pack intervals
e. Type of casing material and thickness
f. Grout horizons
g. Well head completion details
2. Number of wells to be constructed in unconsolidated
material: 1
3. Number of wells to be constructed in bedrock: 0
4. Total number of wells to be constructed:
(add answers from 2 and 3)
5. Estimated beginning construction date: Feb. 2020
6. Estimated construction completion dale: May 2020
Continued on Reverse

ADDITIONAL INFORMATION
1. As required by 15A NCAC 02C .0105(f)(5), attach a scaled map of the site showing the locations of the following:
a. All property boundaries, at least one of which is referenced to a minimum of two landmarks such as identified roads,
intersections, streams, or lakes within 500 feet of the proposed well or well system.
b. All existing wells, identified by type of use, within 500 feet of the proposed well or well system.
C. The proposed well or well system.
d. Any test borings within 500 feet of proposed well or well system.
e. All sources of known or potential groundwater contamination (such as septic tank systems, pesticide, chemical or fuel
storage areas, animal feedlots as defined in G.S. 143-215.1013(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
2. As required by 15A NCAC 02C .0105(g)(3), for wells screened in multiple zones or aquifers, provide representative data on the
static water level, pH, specific conductance, and concentrations of sodium, potassium, calcium, magnesium, sulfate, chloride,
and carbonates from each aquifer or zone from which water is proposed to be withdrawn.
3. Attach any water use permits (if required). [e.g. Central Coastal Plain Capacity Use Area Permit is required in 15 eastern NC
counties by INC Division of Water Resources, visit: http://www.ncwater.org]
SIGNATURES
The Applicant hereby agrees that the proposed well(s) will be constructed in accordance with approved specifications and conditions of
the Water Supply Well Construction Permit as regulated under the Well Construction Standards (Title 15A of the North Carolina
Administrative Code, Subchapter 2C) and accepts full responsibility for compliance with these rules
Signature of Applicant or *Agent
William Jefferys
Printed name of Applicant or *Agent
President of A.C. Schultes of Carolina, Inc.
Title of Applicant or *Agent
* tf signing as Agent, attach authorization agreement stating
that you have the authority to act as the Agent.
If the property is owned by someone other than the applicant, the property owner hereby consents to allow the applicant to construct
water supply wells as outlined in this Water Supply Well Construction Permit application and that it shall be the responsibility of the
applicant to ensure that the water sypply well(s) conform to the Well Construction Standards (Title 15A of the North Carolina
� , /77 9drginislrative Code, Subchapter 2C),
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Printed name of Property Owner (if differe t than Applicant)
DIRECTIONS
Please send the completed application to the appropriate Division of Water Resources's Aquifer Protection Section Regional Office:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, INC 28778
Phone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, INC 28301-5094
Phone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107
Phone: [phone]
Fax: [phone]
GW-22W (Rev. 8/13)

A.C.Schultes afcarerna
SINGLE CASED WELL DRAWING FOR PERMIT APPLICATION
Rotary Table:
+ 2 FT
Ground:
0
Borehole Dia:
20"
Outer / Pit Casing Diameter
18"
Outer Casing Material: BLACK STE
Bottom Of Pill Outer Casing 40 FT
Inner Casing Dia: 8" PVC
Inner Casing Material. SDR 17
Cement grout
Top of Gravel. 50 FT
Top of Screen:
200
Screen Dia:
8" PS
Screen Material.
304 SS
Screen Slot:
.030
Gravel Size:
SOUTHERN # 2
Bottom of Screen:
230 FT
Top of Screen: 260
Screen Material: 304 SS
Screen Slot: .030
Bottom of Screen: 280 FT
Cellar Material: 304 SS
Bottom of Cellar. 285 FT
DRILLING DATA
Owner:
ROOKS FARM SERVICE
Job Name:
IRRIGATION WELL # 1
Job No:
C-1081
Well Number:
# 1
Location:
715 MALPASS CORNER ROAD,
Datum:
GROUND
Static Level (Ft):
Test Pumped (Hrs):
Flow Rate (GPM):
Pumping Level (Ft):
Draw Down (Ft):
Spec. Capacity (GPF):
Screen Mfg.:
ALLOY
Grout Material:
CEMENT
Grout Quantity (CYDS):
4
Drilling Rig:
VERSA DRILL 100
Driller:
JEOVANY BAUTISTA # 4125 A
Date Well Completed:
GEOLOGIC DATA
Depth From Ground
Well Log

SUBMERSIBLE TURBINE PUMP
FT
187 FT
4" 304 SS THRD
TEE
8" X 4" WELL SEAL
°RTA-LOK DROP PIPE
5.39" DIA
MATERIAL OF CONSTRUCTION
Bowl STAINLESS STEEL
Impeller STAINLESS STEEL
Bowl Shaft 416 SS
Shaft Coupling 316 SS
Bowl Bearings SS
Bowl W/R N/A
Strainer 304
Impeller W/R NIA
PUMP
Mfr GRUNDFOS IModel
425 S 400-
GPM 400 jTDH
266 FT TDH
Depth Gauge: NO Required: Not Required: X
Air Line: Required: Not Required: X
MOTOR
HP 40
RPM 3450
Phase 3 PHASE
Hertz 60
Voltage 460 VOLT
CABLE
Size # 6/3 W GRND
Length 200 FT
Type DOUBLE JACKETED FLAT
JUNCTION BOX
Required: BY OTHERS
Not Required
RISER
Pipe Size 4"
ISection Length 20 FT
OTHER SPECIFICATIONS
Check Valve YES
Size N/A
Fluid WELL WATER
Temperature 58 DEGREES
Spacing IN PUMP
Material 304 SS
pH 8
No. Units Required 1
Customer:
ROOKS FARM SERVICE
Address:
715 MALPASS CORNER ROAD
City
BURGAW ST NC Zip
Rep.
A.C. Schultes of Carolina, Inc.
Supplier
A.C. Schultes of Carolina, Inc.

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