GW1-2022-03156_Well Construction - GW1_20220222

i I
rri.LL 1%yVV_1J Por internal use uniy:
1.Well Contractor Information:
Tarrell Benford Graham Jr. 14:wATER: oNEs
FROM TO DESCRIPTION
Well Contractor Name NCWC 2373-A 312 ft• 313 ft• Crack in Rock NC Well Contractor Certification Number 519 rt. 520 ft- Cracklin Rock
iS OUTER=:CASING<.for mulfi.cased wells;OR.LINER.1fa i licalle
Graham Currie Diversified Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 fa 1183 ft. 4.5 ; in- SDR 17 PVC
33QQ(�` 1'6:;WNER;CASINGTOR`TUBING`;"eotherroal-eloseil=too
�/vv
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e. U1C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): fr. ft. in.
Water Supply Well: 17,.SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. tt. in.
Industrial/Commercial DResidential Water Supply(shared) 7718<GR01111
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 23 ft• Hole Plug Poured
Monitoring DRecovery
Injection Well:
Aquifer Recharge DGroundwater Remediation
19:<SAND/GrtA'VEL.PACK. if a`pliable),;
(. Aquifer Storage and Recovery Osalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
..`Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer X DRILU G LOG:attacheadditional?sheets:ifnecessa
Hi-Geothermal(Heating/Cooling Return) -) Other(explain under 421 Remarks) FROM I TO DESCRIPTION(color,hnrdness,soiltrock type, rain size,etc.
0 ft. 25 ft. yellow/orange sand
4.Date Well(s)Completed:12/14/2021 Well ID# 25 ft. 69 ft. hard grey./brown clay
5a.Well Location: 69 ft. 93 ft* hard grey clay
Craig French 93 ft. 119 ft. grey/brown sandy clay
Facility/Owner Name Facility ID#(if applicable) 119 ft. 152 ft. hard grey clay
363 Summer Creek Trail, Vass NC, 28394 152 ft- 171 ft- grey slate rock
Physical Address,City,and Zip 171 ft. 565 ft. grey
Moore 20010463 r " "
3L`REMARRS County Parcel Identification No.(PIN) FEB 2 2 /u?n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Certification:
��� 3�St7,/ C .l`•rmiilvrar`t'1J',a, �i vL Jlv"
G.Is(are)the well(s) Permanent or Temporary tire of Certi racr Date G/
By signing this form, ere y certify that the svell(s)was re)constructed in accordance
7.Is this a repair to an existing well: E)Yes or 9No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards•and that a
/f 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 OW-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: 565 (ft.) 24a. For All Wells: Submit ithis form within 30 days of completion of well
Fo•multiple wells list all depths if different(example-3 a 200'and 2@/00') construction to the following:
10.Static water level below top of casing: 142 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
t
It.Borehole diameter:4.5 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Mud Rotary and Air above, also submit one copy if 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 Servicc'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Suoly& Iniecl
o tion 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 Ito the county health department of the county
where constructed.
i
i
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

Permit tt 33986 PID or LRKM 20010463 Page 1 of 2
Property Address 363 Summer Creek Trail Vass,NC j Number of Bedrooms
� l
°F ,00 Moore County Health Department
Environmental Health Section
per} 1784 P.O. Box 279,Carthage,NC 28327
Phone:[phone] Fax:[phone]
NaR1N Ga
Well Permit
Applicant Name: Craig Thomas French
Applicant Address: Same'as above
Phone: [phone] Email:
Property Address: 363 Summer Creek Trail Vass, NC
Type of Well: Private X Irrigation:
Geothermal ,Agriculture:
Number of Persons to be Served: 4 Number of Con ections: 3
Date.: 4/22/2021 Env. Specialist: cet'
* Well shall be installed as shown on permit, Well permit is vaFr for five ye .s 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: 611-A i Phone,#9140 6-7.J-2--erg./
Signed: Date A7 rD.1. 21
Grout Inspection By: _ Date 7�13/ L
Well Head Inspected By: Date:
Bacterial Water Analysis.Report: Date Taken: Date Received:
Inorganic Water Analysis Report: Date Taken: Date Received:
Nitrate/Nitrite Water Analysis Report: Date Taken: Date Received:
Certificate of Completion: Date:
MCEHD July 2020
,f
i .

County of Moore '
Vepartsnent of Ja feaah
7o5 Pinehurst Avenue• P.O. Box 279
Carthage, North Carot7na 28327
Telephone: [phone]
Robert R.•Wittmann, M.P.H. Medical Records Fax: [phone]
Director Administration Fax: [phone]
Designation of Legal Representative
Mowery-Family Trust, Joseph M Mowery, Alison 5 Linn-Mowery, Trustees
hereby authorize
Property Owner(print)
to serve as my legal
Legal Representative (print)
representative for the purpose of obtaining a permit to install, repair or expand
an on-site wastewater system and/or well. I understand that submittal of the
application for evaluation will authorize the Moore County Health Department to
perform said evaluation on my property.
Address of Property: 363 summer Creek Trail , Vass NC 28394
LRK # 20010463 Lot 7
DocuSrigned by: Docu$lgned by:
slgnat rho U, Nl I�IbW Q�iSbin, Inln,—�lbW Date 3/12/2021 7:54 AM PST
BCE80E39392A4g7... Prope ,q Vp�g39r 4B7,,,
Signature Date
Legal Representative
"To Protect and Promote Health through Prevention and Control of Disease and Injury"
http://w,ww.moorecountync.gov/health/
Environmental Health WIC
Telephone: [phone] Telephone:' 910-947-2797
Fax: [phone] Appointments: 910-947-3271
Fax: 910-947L 2460
i

J • 4VV Y I
/ r Yr rww�i it l�:.i.rr ril rlii irwww+i ii�Ji r•w rii ar.ii w•1r d.�•wsie irii� ^+wilt.�:,:t
/:
Wb
t .1` . . :• 1 .vim :r••:. ,t .r,`•,•.;:. <'.t
Well
of
Ouse
..! \'t,.' "' ,�gypp �� a+J�,; •'''. 'i ;•r;� 4;t
C r. i t '•I '
--------------
.:___- t........( t
Q i.. •� is
363
U Creekr1