GW1-2022-10470_Well Construction - GW1_20221118

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WELL CONSTRUCTION RECORD(GW-1) �— For IntcrnAl"Usc—Only:
1,Well Contractor Information:
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Well Contractor Nan• FROM ,TO DESCRIPTION
_ t 3 boo
rt. ft.
NC Well Contractor Certification Number 15:',OL'If11ER...GASIi�'G foe?nuth e�sed5ells URaCINER;lEa" hcnitle
�� FROM TO DIA ETER THICKNESS MATERIAL
--�� ��"rYY)--��/}a/�1�12 t _ /►�r+� �.�'�� � ft. ft. in. e .
Company Name
•� LfislN.k} %G G12R:T ASIN ' UBI G 'eotfien 'li@Idsadloa
2.Well Construction Permit#:- 313 �q 7^pt FROM TO DIAMETER THICKNESS MATERIAL
List all applicable tvel/Construction permits(i.e.U1C,County,Stare,Variance,etc.) ft. I
in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: GAVEM
FROM I TO DIAMETER SLOTSIZE I THICKNESS , MATERIAL
€Agricultural Municipal/Public t. �- ft. In.
Geothermal(licating/Cooling Supply) residential Water Supply(single) ft. In.
industrial/Commercial Residential Water Supply(shared)
Irrl ation FROM I TO MATERIAL I EMPL CEMENTIffh'd AMOUNT
Non-Water Supply Well: ft.
Monitoring �'V ;� Recovery ft. ft.
Injection"Veil: ft. ft
Aquifer Recharge OV/,4 E]Groundwater Remediation
1%;SANDIGRAi\!FiL PACK?iGa I liculil
Aquifer Storage and Recovery LD..`Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage fr.
Experimental Technology iSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.^DR•I[vL1NG,:liOG:nttticFi:ndditiofiili'slfeafs[Ftice3Sd
F _
Geothermal(Heating/Cooling Return) Other(explain tinder#21 Remarks) FROM TO DESCRIPTION color,hardness solVrock e, ,aim size,etc.
fr. ft. r A L 6 G
ft,. fr•
4.Date Well(s)Completed: ®4 Well ID# �b
Sa.Well Location: ft. ft.t�
Facility/OwnerNamc Facility ID#(ifapplicable) ft. ft.
d5(o l-r- kevi Ew Pgss 1Zocl�;��hcxrY► i�1� ft. ft. NOV 1 8 2022
Physical Address,City,and Zip ft ft.
I 1"
2112EN1ARICS,...� , _
re-14Mc t;;,1V'0> ply 35Da �I�I do 9 �.�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lo n Q ng is sufficient) Certffie '
35. obai9b N 1 1 . 6 p r ! t6 1
6,is(are)the wells) Permanent or OTemporary Sigma re of Certified Fell n .ct Date
By cerlify t at t to u•e11(s)u• were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or MAO with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consa•uclion Standards and that a
1ftltir it a reliair,fiil aril knolvn well consiriictimt inJorutation mid explabi the nature ofdie copy ofthis record has been provided to the well oumer.
repair under i121 remarks section or on the back ofthis form. '
. 23.Site diagram or additional well details:
8.For Geoprobe/DPI'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,ogly 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i�(. 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: A) 24a. For All Wells: Submit this form within 30 days of completion of well
h'ar multiple wel/s list all depibs(f diijferenl(example-3 rer 200'and 2@1001 construction to the following:
10.Static water level below top of casing: � V I (ft.) Division of Water Resources,Information Processing Unit,
Iftvaier level is above caring,use' 1617 Mail Service Center,Raleigh,NC 27699-1617'
11.Borehole diameter: 24b.For Infection 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: (!t(Q A1►4 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) Method of test: 24c. For Water Sunmly&Iniection Wells: In addition-to sending the form to
the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Foot GW-I Notth Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I

OCT Z 4 L011
1For OfficeYUse Only
WELL CONSTRUCTION PERMIT r }
Richmond County Health Department Cps File Number 373847 2
127 Caroline Street 'RtN Number
74350Z777009
Rockingham, NC 28379
f t Phone: [phone] FAX: [phone] T� Loot Y
Tax Block#
Evalttafed For WELL
PERMIT VALID UNTIL:
Property Owner:Sarah Carter Applicant: Sarah Carter
Address: 7 Scots Glen Dr Address: 7 Scots Glen Dr
City: Southern Pines City: Southern Pines
State/Zip: NC 28387 State/Zip: NC 28387
Phone#: (910)997=1385 Phone#: [phone]
Property Location & Site Information
Address/Road#: Subdivision: Ghalks Landing Phase: Lot:
256 Lakeview Pass Proposed use of Well: SINGLE FAMILY
Rockingham, NC 28379 If Other:` _
Latitude: c
Applicant Email: [e-mail]-
Longitude: _-71, 7G i.c5
Owner Email: [e-mail]
Directions
out Blewett Falls Rd,take Chalks Landing gate at Lakeview Pass,site on right as going down hill
Well Contractor Information M
Drilling Contractor Driller Registration
:.Permit Conditions
Permit Conditions
New well must be 50ft minimum from entire septic system and be 25ft minimum from entire building perimeter, including
attached porches and decks.
i
Well location,construction and protection must meet all state and local regulations and must be inspected and approved by an authorized representative of the Local
Health Department.The permit may be revoked at any time for failure to comply with existing regulations.The siting of approved well construction area(s)by the Health
Department is to provide protection from the known possible sources of contamination.The approved well area(s)may not be changed without permission from an
authorized representative of the Local Health Department,Issuance of this well permit does not guarantee water quality or adequate water production from the well once
it is installed or repaired.
Issued By: 2001 - Date of IssueP6/15/2022
Authorized State Agent:
Owner/Applicant Signature: Page 1 of 1