GW1-2022-08612_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1: ell Coittractor Information:
ryu 14.WATER ZONES
Well Contractor Nanle FROM TO DESCRIPTION
19 ft. s �- ► -e,,
ft. ft.
NC Well Contractor Certification Number \ 15.OUTER CASING(for.multi-cased wells)OR LINER(if a
` Ilcable
!I - r �fm\ ( FROM TO DIAMETER THICKNESS MATERIAL
J �/ ` f I ft. , 'n ft. in. p c 1 e� VG
Company Name w 'S V
16.INNER CASING OR TUBING•( eolhernral closed-loop).
2.Well Construction Permit#:_ FROM TO I DIAMETER THICKNESS 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETERPULP
ICKNESS MATERIAL
Agricultural []Municipal/Public lLe ft. Iiol ft. m `Geothermal(Heating/Cooling Supply) FIResidential
esidential Water Supply(single) ft. _1 ft. in.
Industrial/Commercial Water Supply(shared) 18.GROUP.
_ hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
JD Monitoring DRecovery
Injection Well:
Aquifer Recharge rl Groundwater Remediation
19.SAND/GRAVEL.PACK(if 3 'licablc)
(- Aquifer Storage and Recovery QlSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_-.Aquifer TestI Stonnwater Drainage CJ ft. J9 ft.
Experimental Technology QlSubsidence Control ft. ft.
(�IGeothermal(Closed Loop) [M]Tracer 20.DRILLING LOG(attach additional sheets if necessary'.
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,eta)
_ Geothermal(Heating/Cooling Return) []]Other Other(explain under#21 Remarks) ft. ft.
Q� -hews 0 1 w
4.Date Well(s)Completed: " a 1 Well ID# ft, ft. 5m h 1 a
ft. fc. 0nt n —r e
Sa.Well Location:�J a WkidrNM AC t/�
I loft. ft. n n Y iLV
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
A orl :1U I Q� U 666 N L Z ft. ft.
Ph sicaI Address,City,and Zip ft. ft.
DOR ��8- �� 21.REMARKS MAY. 202
`
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ty l - �k
.Yet U1TIYJiIE''r1!✓st,til:ai`•'.�.7 Jh�i i
(ifwell field,one lat/long is sufficient) 22.Certification:
3,5 Y aOaos(P N , -7 w
(
6.Is(are)the well(s) ( Permanent or IOTemporary Signature of Cet red Well Contra or Date
TT ,, By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QIYes or I , o with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction it formation d explain the nature of the copy of this record has been provided to the well owner.
repair under 421 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: 19
(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1fdiere»t(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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:_M� (RD -arv, 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) D Method of test: O'Y1 1r) 24c.For Water Supply&Iniection 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: M 10 Amount: IN l 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 Resources Revised 2-22-2016
i ,

YJ
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
Roy COOPER MANDY COHEN,MD.MPH
GOVERNOR SECRETARY
MARK BENTON
DIRECTOR
Onsite Water Protection Branch
October 26,2021
James M.Hair
2785 Gobbler Ln.
Fayetteville,NC 28312
RE:Approval No. 1273
Well Cased to Less Than 20 Feet—Rule 15A NCAC 2C.0116
6301 Brandon Tyler Ln.,Linden,NC
Dear Mr.Hair
On October 25,2021,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 6302 Brandon Tyler Ln.,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(919) -270-9665
Sincerely,
Wilson Mize R.E.H.S
W W W.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 OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER
I ;