Lily Commercial Site_20160302

Jim
From:
Barber, Jim
Sent:
Wednesday, March 02, 2016 3:54 PM
To:
'Peggi Johnson'
- Cc:
'Benford Graham'
Subject: RE: Application capacity well NAV
Attachments: Lily Commercial site LRK 38700.docx; Lily Commercial 11 sites Parcel IDs.pdf,
Ms. Johnson;
After looking over the information provided, I have a few questions and comments:
1). How many wells are being permitted under this application? The bottom of page one is incomplete with respect to
the number of wells being'permitted. In the application there are five Moore County Health Department-(MCHD)
permits and of the five, four of the permits have well construction records associated with them.
2). The most recent MCHD permit dated 2 March 2016 doesn't indicate the well location (i.e. 266 ARO Road— LRK 38700
as the other four permits do). Is this well permit also for the 266 ARO Road location or LRK?Parcel ID:38700? Please see
the attached map from the Moore County GIS website that indicates the property identified as LRK 38700 (blue line).
3). If there are five wells being,permitted consistent with the number of applications presented in the emailed
application; do all five wells reside on the same piece/parcel of Lily Commercial property or have wells been installed or
will be installed on 5 of 11 parcels that Lily Commercial owns adjacent to one another?
4). If there are five wells to be installed on five separate parcels of property; then I need the individual properties
identified with the approximate well location on each parcel (see attached pdf map.with the Parcel ID number for the 11
properties owned by Lily Commercial).
Thanks
Jim Barber
Environmental Engineer
NCDENR-DWR-APS
Fayetteville Regional Office
910-433-3340 voice
910-486-0707fax
i im.barber(a�ncden r.gov
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and
may be disclosed to third parties.
`', Go Green! Print this email only when necessary. Thank you for helping NCDENR be environmentally responsible.
*******************
From: PeggiJohnso&[mailto:[e-mail]]
Sent: Wednesday, March 02, 2016 10:21 AM
To: Barber, Jim <[e-mail]>; Benford Graham <[e-mail]>
Subject: Application capacity well NAV

3/2/2016
Mr. Barber
See attached
Peggi
PeggiJohnson
Graham Currie Diversified Drilling, LLC
4532 N C Highway 73
West End, N. C. 27376
Phone[phone]
Email: Peggi(@gi:ahamcurne.com

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3/2/2016
GRAHAM CURRIE
4532 N C HWY 73
WEST END, N C 2737G
MR'. BARBER:
RE: BORTINS "NAV" - CAPACITY WELL
LILY, LLC
PLEASE REVIEW THE ATTACHED AND
CONTACT BENFORD WITH ANY QUESTIONS
THANKSI
PEGGI
[e-mail]
910-639-1876

NORTH CAROUNA 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 Svstems with a Design Capacity of 100,000 Gallons Per Day or Greater)
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. Date: ,? XeO / 4 FOR OFFICE USE ONLY
2. County. /%OGRE PERMIT NO. ISSUED DATE:
3. Applicant (3&IQAM CURRIt T Telephone:
Applicants Mailing Address: if j 3 � Ire //wy y,3, WA st
Applicant's Email Address (if available):
4. Contact Person (if different than Applicant):
Contact Person's Mailing Address:
Contac Person's Email Address (if available):
Telephone:
6
5. Property Owner (if differ ant than Applicant): z/,lyCoH.+eeCiAt LIC Telephone: [phone]
Owner's Mailing Address: 9?5- G,e ,y t St {ails Syp A //d N C R 73 7 G
Owner's Email Address (if available): V6 ® }/A /10 O . Carl
6. Property Physical Address (including zip code) and PIN Number: see /f 1/4 dre
7. Intended use of Well or Well System:
(examples: irrigation, consumption, e
8. Will the proposed water supply well or well system replace or be added to an existing well or well system?
(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):
10. If adding a well to an existing system, list the existing water supply wells in the existing system and their respective yields:
N LA
11. Is this a public well or well system? /1(0_
If yes; give Project Engineer and contact information:
If yes, give Public Water ID Number: . N/-'
12. Well Contractor. frRA & M C aRRi iti Well Contractor Certification No.: -13 Z 3-A
Well Contractor Address: grs2 NC jk y 93, {'✓� s� owd, N C 1 lyig
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. Sandlgravel pack Intervals
e. Type of cosing material and thickness
f. Grout horizons
g. _ Well head completion details
2. Number of wells to be constructed in unconsolidated
material:
3. Number of wells to be constructed in bedrock:
4. Total number of wells to be constructed;
(add answers from 2 and 3)
5. Estimated beginning construction date:
6. Estimated construction completion date:
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. 143-215.10B(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 NC Division of Water Resources, visit: http://www.newater.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
inistrabye Code, Subchapter 2C) and accepts full responsibility for compliance with these rules
1
Si natu f ant 'Agent Title of Applicant or 'Agent
%ml?ei # 13 GX.4h114 YA •Ifsigning asAgant attach authorization agreement stating
Printed name of Applicant or *Agent 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 theeater supply well(s) conform to the Well Construction Standards (Title 15A of the North Carolina
Administrative Code, Subchapter 2C).
Mt�C go beAt 13og4iHs MG -&-
Signature of Property Owner (if different than Applicant) Printed name of Property Owner (if different 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, NC 28778
Phone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 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. 8113)

W
Moore County Health Department
Environmental Health Section
PO Box 279, Carthage, NC 28327
Phone [phone]
"' '•"
Fax [phone]
APPLICATION FOR WELL PERMIT
Receipt N: //++ Parcel ID/LRK q:
Name: JL (O' MNBRCiAl 11C Re&Ar /3oR ns Home Phone q:
Mailing Address:.?JfS GRAtft 5r Cell N:
ANd AIC a13Email: 40ebYV5CA/foo.CoM
WELL TYPE: Private Drinking Agricultural Irrigation
Geothermal Vertical Monitor .
Number of connections: Number of People Served:
Directions to property (911 address if possible):
State rules require the following:
W611 drillers and pump installers are responsible for properly disinfecting wells after construction.
Homeownera,must call'the health department to request water samples after disinfection to insure the water
supply is safe for human consumption.
Sketch out the house, septic tank area, underground storage tanks, etc. Well site should be located in a well
drained area at least 100 ft. from possible sources of contamination.
Note: Well permit expires twelve (12) months from the date of issuance.
NC WA R s,L)pplH well U1d��l�n e�rp'tc�fy Ioo,Ood 9p- peRd.iy
The well site will be located using the information provided by the property owners or their agent.
The Health Department is not responsible for improper location of wells due to erroneous information
provided to the Health Department, improper location of wells by the contractor, quality or quantity
of the water supply.
(Dat
Sign
(O r esentativ )
"ICHD-EYV 9113

Permit No: 1 2-1 Z'S'
SS7a 0
tieil?s�tc, 9-=Z4 r s g
Well Permit
a
Moore County Health Department
Environmental Health Section
PO Box 279, Carthage, NC 28327
Phone [phone] Fax [phone]
pp U N3, 40t- %L?DVo
Name: Phone #:
Address: Z5'7 ��,.A,�h f - 1t�1=
Type of Well: Private . Geothermal Irrigation X_ Agricultural
Number of Persons to be Served: a�kC�i�_ I� Number of Connections 1 +
Well Contractor:
Permit Issued By:
Phone #:
Well shall be installed as shown on permit. Well permit is valid for five years
from the date of issue. Notification must be given to Environmental Health
when well becomes operational so that water samples can be taken.
Well Setbacks:
D wiz minitnum from any septic system
D 25 ft minimum from any foundation
D 50 ft minimum from any source of contamination
➢ ioo minimum from barn, chicken house, dry stack area
** Avoid areas that may collect surface water, such as depressions and concave areas.
Well construction record provided to: Health Department ❑ Owner 13
I certify that the well constructed on the above property meets all requirements of 15 NCAC 2C Well
Construction Standards.
Signed:
(Well Contractor)
Grout Inspection By:
Well Head Inspected By:
Bacteriological Water Analysis Report: Date taken:
Inorganic Water Analysis Report: Date taken:
Nitrate/Nitrite Water Analysis Report: Date taken:
Certificate of Completion
MCHD-ENV 8/ 15
Date:
Date:
Date:
Date received:
Date received:
Date received:
Environmental Health specialist
Date

North Carolina Depumnent of Emironmem and Nanual Resources . Division of Water Quality
ONTRACfOR(INDI\'IDLAL)NANLE IPrim) C'ERTTFIC.ATION0
WELL C'ONTRaC'TOR COMPANY NAME b7e It -Dr )l - R PHONE I ( 1
STATE WELL C'OISTRUC'TION PERMITa ASSOCUTED WQ PE"IFTa
(if applicable) (if 1phcaMa)
1. WELL USE.(Check Applicable Box): Residential Cu Municlpal!Public ❑ Industrial ❑ Agncultur l'❑
Monitoring ❑ Recovery ❑ Heat R'6p Water Igiection C Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: °� County &2"e
(Street Noma Nu^Vm%/ %..C'omrmumn:Subdn:sinn.Loi No Zip Cotle)
3. OWNER: is"
rr
Address
ISiramor R... No.I
4.
6.
6.
7.
a.
9.
10.
12.
City or Towu Suk Zip Code
Area wdo Plim numbs
DATE DRILLED_ I - z-1 -1ta_
TOTAL DEPTH:
DOES WELL REPLACE EAI TELL^ YES O NO CHI
STATIC WATER LEVEL Below Top of Casing: �_FT.
Tnp of Casing)
TOP OF CASING IS :LJ— FT Above Land Surface-
-Top ornsrng irrminvni wVor below nand surface requires a
rMaKa 4 acrordaKe tt tth 15.4 NCAC ?C .el l8.
YIELD (gpm): TMETHOD OF TEST
WATER ZONES (depth): r (04 io 73
y$(c •hl ri I r
DISINFECTION: Type_ \Amount
CASING: Wall 77 ckness
Depth Diameter or WoighvFt. Matenal
From,_;l_To G.,' Ft Og xJ,
From_13_ To j� Ft q_ ,.,e
From To F t.
GROUT: Nk ih Matenal method
From To Ft.
From To Ft.
SCREEN: Depth iDiameter Slot Size Material
Fromm To 13 Ft. 4ur in.�S�
From To. (_ Ft 4 in. in. _ 5f -
SAND/GRAVEL PACK '7
Depth Sr[e tatenal
From_n ToZq Fr J_%�i'Pit 6rqUe
From To Ft.
16. REMARKS:
Topographic/Land setting
❑Ridge Mope ❑Valley ❑Flat
(cbeck appropriak boxT
Latitude/longitude of well location
(degrtes•minuk•Dods)
Latitude•longimde scii=:❑GFS❑Topographic map
(chat box)
DEPTH DRILLING LOG
From To Formation Description
in - 3
3 2t,
do �y d/cL )r llv a
2c - 31 otn • a+'a�lSud
It tl% _
.i s_A
s 51
•fin 74 iueA
19 1;1. s.. +CPwL_
$I 190 All
in 91 �—
ttl • '+4 fACAT10N SKETC stay tS4l�
Show directijou and distance in miles from at least
two State Roads of Count, Roads. Include the road
numbers and common road names.
)o
a
ID(;11
drff- e-
I DO HEREBY CERTIFY THAT IKiS WELL W'AS CONSTRUCTED IN ACCORDANCE WrrH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSQ CONSTRUCTING THE WELL DATE
Submit the origival to the Dlrision of Water Quahty, Attu: Information Managementt 1617 Mai! Service Ceattr
Raleigh, NC 27699.1617, Phone No. [phone], within 30 days. y
GWI REV.09;2004

J,
Well Permit
Moore County Health Department
®� Environmental Health Section
PO Box 279, Carthage, NC 28327
t? Phone [phone]
Fax [phone]
Permit No:
Name: e c<ti " Phone #; 9/0. 9S). z1683
i
Address: LSD �..a/, i 5�ke� f &3� f- ('� t/-
�1.0 8.t10A'.��'����i2�4�n•��"`�'��;,y�.c%"�^3`4"a�7-"o'.z%lcasr�y��ew"?rfl-Ffii%
Type of Well: Private Geothermal
Number of Persons to be Served:
Well Contractor:
Permit Issued By:
Irrigation v Agricultural
Number of Cotmections /
Phone #:
• Well shall be installed as shown on permit. Well permit.is valid for five years
from the date of issue. Notification must be given to Environmental Health
when well becomes operational so that water samples cari be taken.
Well Setbacks:
➢ / vu miaimnm from any septic system
D 25 ft minimum from any foundation
D 80 ft minimum from any source of contamination
D i DO minimum from barn, chicken house, dry stack area
** Avoid areas that may collect surface water, such as depressions and concave areas.
Well construction record provided to: Health Department O Owner 11
I certify that the well constructed on the above property meets all requirements of 15 NCAC 2C Well
Construction Standards.
Signed: Date:
(Well Contractor)
Grout Inspection By;
Well Head Inspected By:
Bacteriological Water Analysis Report: , Date taken:
Inorganic Water Analysis Report: Date taken:
Nitrate/Nitrite Water Analysis Report: Date taken:
Certificate of Completion
Date:
Date:
Date received:
Date received:
Date received:
Environmental Health specialist Date
MCHD-ENV 9/ 15 1

1—
r•" North Carob• Depamnent of Emi
��LCONTRACTOR(INOIVIDUAL)NN AE Ipriot)_
.//R!LLCON-MMORCO\1PANYN&NIE ram"
STATE WELL CONSTROCTION PERhi1TM l f
Resources • Division of Water Quality
WQ PERMIT1
C'ERTTPICATION a_
PHONE e ( )
1. WELL USE (Check Applicable Box): Residential ❑ .1 Muhicipal.ftblic ❑ Industrial ❑ Agriculmial ❑
Monitoring 0 Recovery ❑ Heat Rump Wnter Ini4tion*0 Other ❑ if Other, List Use
2, WELL LOCATION:
Nearest Towu: fd04County
fSveelNmm.Numbert. Community. Subdicuion. Lot No
3. OWNER:
Address t _
\ 15vrcr nr Rru:e r:o.l
Ara aide. Plum number
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YE
7. STATIC WATER LEVEL Below Top of Casing: _
IL°sr •• .... it'Above Top
8. TOP OF CASING IS fy FT. Above Land
aToporarlee termhuted avor below land surface require
eartan" V oanrdaoce mltr ls.A NCAC X .0115.
9. YIELD (gpo): n METHOD OF TEST_
10. WATER ZONES (depth): ' "- TX
11. DISINFECTION: Type_ N7N- Anu
12. CASING: wall
Depth Diaoeter
From _Q_ To� (g? Ft
Fromm Tom N
From-f Tom
13. GROUT: Depth Matenal
From To Ft.
From TO. Ft.
14. SCREEN: Depth Diameter
From(- To_7sL Ft._#_ui.
From VT To ) t3 Fi _emu).
15. SANDIGRAVEL PACK:
Depth Size
From—.a_To_19� FL l.(Pw
From To Ft.
16. REMARKS:
or weight,
rc
Ale_
1p�—
Slot Size
—30
NO ❑
Topographic/Land setting
❑Ridge MSIope ❑Valley ❑Flal
(check appropriatebox)
Latimdellongimde of well location
1.1 35:114LeA* I-n -79.a1 6L•90
(deiices minuus:ueoa )
l aiimde•1ongimde source:❑GPS❑Topographic map
Icheck box)
DEPTH DRILLING r_flf_.
From To FormationDrAhption
7 fC�.�
Vs - 9Y ereir.
ql+r -4B Tlk
LOCATION SKETCH
Show direcl)ou and distance in miles from at least
two State Roads or Count•-j Roads. Include the road
'Matenal number's and common road names.
Scl Yg
jra f4
MUA
ethod
C:
I DO HEREBY CERTIFY THAT THIS ti'ELL WAS CON : UETED IN ACCORDANCE W Mi 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THr5! RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�IGti.4TURE OF PERSOR CONSTRUCTING STRUCTPIG THE WELL DATE
Submlttk original to the Division of Water Quality,'Atthl Informs* MinigenenG 1617,,%I5cniceCnrcr-
Raleigh, NC 21699.1617, Phone No. (919) 733401 s, nittl' 30 days,
GW.1 REV.09,n004

Permit No: /316' j
I711,�`^1J' i'ssiie?Date:. ; _z=�a,'7-,7o7i1
Well Permit
Moore County Health Department
• Environmental Health.Section
PO Boa 279, Carthage, NC 28327
Phone [phone]
Fax [phone]
Name: Phone #: 9 ro, 997. 46 83
Address: tiiC-
r-'L-ocatiOR= 'blob=�rd-✓�ae��e �:{ :^.%i n�MLTa by"� wcCC3�
Type of Well: Private Geothermal Irrigation Agricultural
Number of Persons to be Served: Number of Connections
Well Contractor: Phone N:
Permit Issued By:
Well shall be installed as shown on permit. Well permit is valid for five years
from the date of issue. Notification must be given to Environmental.Health
when well becomes operational so that water samples can be taken.
Well Setbacks:
➢ /Vd minimum from any septic system
D 26 ft minimum from any foundation
➢ 60 it minimum from any source of contamination
/i�'D minimum from barn, chicken house, dry stack area
** Avoid areas that may collect surface water, such as depressions and concave areas.
Well construction record provided to: Health Department IJ Owner t7
I certify that the well constructed on the above property meets all requirements of 15 NCAC 2C Well
Construction Standards,
Signed:
(Well Contractor)
Grout Inspection By:
Well Head Inspected By:
Bacteriological Water Analysis Report: Date taken:
Inorganic Water Analysis Report: Date taken:
Nitrate/Nitrite Water Analysis Report: Date taken:
Certificate of Completion
MCHD-Fr1V 8/ 15
Date:
Date:
Date:
Date received:
Date received:
Date received:
Environmental Health Specialist
Date

W Irku%—l I• Ll
u
i North Carolina Deparhnent of Emironment and Natural Resources - Division of water Quality
WELL CONTRACTOR (MI\TDPAL)NANtE (prlot) 'rmes W. (ERTTFICATIONa
WTLL CON'TfU(TOR ('O\IPA:VY NA,I,IE /WrA ,. A1,11 Dn I&.. PHONE r ( 1
STATE WELL-C'ONSTROC-T(0.N PERMITa ASSOCLITED WQ PEMITTr
(Japplrcable) (if applicawt)
1. WELL USE (Check Applicable Box1- Residential ❑ Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Infection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: ` Jxjz4i& erws County ,,,r,,.,/e
(8ueetNmu, Numbns. G+mmumn. $ubdn+su+n L.+: No.Zip Code) •
3. OWTfER:
Address
15irret or Roux No 1
City or Towu swe Zip Code
Area code- Phan number
4. DATE DRILLED
S. TOTAL DEPTH: 4�6
6. DOES WELL REPLACE EXISTING TELL'? YES ❑ NO l!r
7. STATIC WATER'LEVEL Below Top of Casing: FT.
(r w•_'t1'Above Top ofCasmg)
8. TOP OF CASING IS _ FT. Above land Surface*
•Top of eating tn'tulaated aVor below land surface requires a
r"we is accordance a ttb i. A :`CAC X .0118.
9. YIELD (gpin): METHOD OF TEST
-
TO. WATER ZONES (depth): Y
to IV
to 43
11. DISINFECTION: Type Amount
12. CASING: Wall Thickness
Topographic/Land setting
aKiidge CISiope CIValley ❑Flat
(cheek appropriate box)
Lau on of well location
Hai 36. 19 95-3- Lne-79 36763`
(degreevtninuicv: )
1,atinlde•1onginide source:❑GFS❑Topoglaphic map
(chxk box)
DEPf DRILLING LOG
From To Fortpation Description
Depth Diartet&
or Weighufl. Material
from 0_ToeFt.
From_79To_ -W7 Ft _
Esc SL �1e
From 13 To gs' _ t.11
Jo
13. GROUT: Depth Material
Method
From To Ft
From To F,i
14. SCREEN: Depth Diameter
Slot Size Material
Fromm To 78. Ft m.
'V1
_.I n.
From Tom_Ft W.
3b ia. d
15. SA GRAVEL PACK:
Depth Size
Material
From 23 Tom Ft. l
&4tlye t
From -To- Ft.
16. REMARKS:
Show direcllou and distance in miles from at least
two Stare Roads or County Roads. Include the road
numbers and couunon road names.
O•
I DO HEREBY CERTIFY THAT T HIS WELL W'AS CONSTRU -TED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCIION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRLiCTING THE WECL DATE
Submit the original to the Division of Water Qua I!t}•, Attnt Information Management,1617 ,'•fail Service Ceotcr•
Raltigh, NC 17699.1617, Phone No. (91y) 733.7015. within 30 days.
GW-1 REV. 0,12004

Permit No: / -3/ b o
QRK:= """3 20
Issue_ Date_
Well Permit
yM•� r Moore County Health Department
e i Environmental Health Section
PO Box 279, Carthage, NC 28327
t �n � Ph 4
•�,, one (910) 9 7.6283
Fax [phone]
Name: L e Phone #: 2io. 9 gl. GB3
Address: z �; �'swe t� S� eQ+ 1 iL',..cl . /t%G — —
Type of Well: Private
Number of Persons to be Served:
Well Contractor:
Permit Issued By:
Geothermal Irrigation � Agricultural
Number of Connections r
Phone #:
Well shall be installed as shown on permit. Well permit is Vaud for five years
from the date of issue. Notification must be given to Enviroamental Health
when well becomes operational so that water samples can be taken.
Well Setbacks:
D / oo minimum from any septic system
D 25 ft minimum from any foundation
➢ 50 it minimum from any source of contamination
➢ /av minimum from barn, chicken house, dry stack area
*' Avoid areas that may collect surface water, such as depressions and concave areas.
Well construction record provided to: Health Department 0 Owner 0
I certify that the well constructed on the above property meets all requirements of 15 NCAC 2C Well
Construction Standards.
Signed:
(Well Contractor)
Grout Inspection By: _
Well Head Inspected By:
Bacteriological Water Analysis Report: Date taken:
Inorganic Water Analysis Report: Date taken:
Nitrate/Nitrite Water Analysis Report: Date taken:
Certificate of Completion
MCHD-ENV 8/ 15
Date:
Date:
Date:
Date received:
Date received:
Date received:
Environmental Health Specialist
Date

f✓c�� = .ram
N I R urces • Division of Water Quality 61f
North Carohna Departinent of Ensvonmcnlldud anlrp cso
can.1.CONTRACTOR (INDtnIDL'ALINAbtE grist) Tc`..•r_e5 R �Z - _ C'ERTIFICATIOya_
WELL C'ONTR{C70R('0\iPA,gI NA,\IE fCa/ "e, An ' G PHONE a 1 1
STATE WELL CONSTRIA-flON PERAtlTa ASSOCIATED wQ PERAIRa
I, WELLUSE (Check Applicable Boxi Res)denual C3 I Municipal -'Public ❑ Industnal C3Agricultural ❑
Monitoring ❑ Recovery 0 Hear Rump Water hji4iion C Other ❑ If Other, List Use
2. WELL LOCUTION.
Nearest TOwa:
(Strati Norse. NumM+. G+rmmumn Subdi%;5am LoINo Zip Cock)
3..OWNER.
Address
ISueti rr Ranf< No I
CigmTowu Suit Zip Cale
Ara eodn PbM number
4. DATE DRILLED_-X•/�
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL" YESjo NO O
7. STATIC WATER LEVEL Below Top of Casing. FT.
II'te "-'It Abort Tnp o Casing)
8. TOP OF CASING IS FT Above Land tafaoe'
-Top or tr1Lo{ Ierminatrd stitr ,' lanthurface requlrrs i
. rariaaea IN aPPords", w tth I SA NCAC 217.011$-:
9. YIELD(Bpm): NIETHODOf,TEST
10. WATER ZONES (depths:
Topographic,Land setting
C)Rldge Ctlope Walley OFlat
- ccucck appropr w box)
Lautude%longitude of svcll location
I.
tdegrtca mina s+aaeada) ,
Latinlde•1onginude source: OGPSCITopographic map
(check boa)
DEPTH DRILLING LOG
From To Formation Dcseripdon
'//,mod/
1f ' ZY
25f 5j?
ZS frT_ n<,e Sa.d-Y44
11. DISINFECTION. Type Amount Show direcgou and distance in miles from at least
12. CASING: Wall Tluckrirss two State Roads or County Roads. Inchsde the road
Depth Diameter ni WeighcFt Matenal numbers and cosrunon road names.
From
To
Ft
Flom
To
Fi
From
To
Fr
13. GROUT:
Depth
Material M6thod
Flm
To.
Ft
From
To
Ft. '--
14. SCREEN:
Depth
Diameter Slat Size Material
From
To
F) In in
From
To
F) u) In:
15, SANDIGRAVEL
PACK
Depth
Size Material
From
To
FI
From
To
Ft. �-
16. REMARKS:
_
P
I DO HEREBY CERTIFY THAT T HIS 0.•EL: 'A AS CUNSTR'UCTED IN ACCORDANCE WITH 1 SA NCAC X. WELL
CONSTRUCTION STANDARDS. ,AND THAT .A COPY OYTHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGN..URRE OF PERSO CO STR12CT NG THE WELL DATE
s" the o*ael to the Division Df A'aler Que6tl,.Atm:Information dl,tngement 1617 Mal senio reefer•
Raldth, NC 27699.1617, Phone 1n. (919) '33.701 c• within 34 days.

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I
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SURVEY OF
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FAMILY FARMS,,
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PARCELS
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LILY COIAIERCUO,
LLC

LISTING OF PROPERTY PARCELS
7205 US HWY 1, Southern Pines, NC 28387
PARCEL
PARCEL ID
PREVIOUS MOORE COUNTY ADDRESS
1
38722
266 ARO RD.
2
38700
US HWY 1
3
32671
ARO RD.
4
38291
ARO RD.
5
37476
ARO RD.
6
32672
VALLEY VIEW RD.
7
38292
VALLEY VIEW RD.
8
32842
VALLEY VIEW RD.
9
32841
VALLEY VIEW RD.
10
37474
VALLEY VIEW RD.
11
37475
VALLEY VIEW RD.

Moore County, NC
Page 1 of 1
PARID:00038722
TOWNSHIP:
LILY COMMERCIAL, LLC
Parcel
ParlD I PIN:
Record Type:
Tax Year.
Tex Jurlsdlction:
Tovmship:
Owner
Account Number:
Name:
Mailing Address
Legal
CITYNAME: WEST END
OD0387221858212960944
REAL
2016
A:
07: MCNEILL
97012987
LILY COMMERCIAL, LLC
255 GRANT STREET
WEST END NC 27376
Physical Address:
266 ARO RD
Legal Desoription1:
NIAGARA REALTY LOT 5 '
Zoning:
I
Plat Cabinet:
Slide:
Permits
Permit Dale
Pemut#
Purpose
Open/Closed
21-8EP-15
12125
WELL
2"EP-15
12124
IMP RES
Recorded Transaction
Date
Book
Page Sale PAW
Validity Code
05-AUG-15
4528
484 662.500
DA
3DJUN-08
3436
582 621,000
21-MAY-99
1511
379 0
21-DEC-81
484
938 0
Description
NBHD Code l Name
Class:
Land Use:
Living Units:
Topography:
Location:
Parldng:
Traffic:
Utilities:
Restdcdons:
Deeded Acres:
Calculated Ames:
VC Notice I VC Data:
Valuation
Appraised Land:
Appraised Building:
Appraised Total:
Deferred:
Exempts/Excluded:
Assessed Real:
Personal:
Total Assessed:
731:
CV: COM VACANT
COO: COMMERCIAL VACANT LAND
0
1:LEVEL
1 ;ALL PUBLIC
5.58
5.58
R: 17-MAR-15
131,6DO
0
131,600
0
0
131,609
13l,600
266 ARO RD
NBHD: 731
ROLL: REAL
http://icare.moorecountync.gov/careprdIDataletsIPrintDatalet.aspx?pin=00038722&gsp=P... 2/26/2016

Moore County, NC
Page I of I
PARID:00038700 _
TOWNSHlp:
LILY COMMERCIAL, LLC
Parcel
Pero / PIN:
Record Type:
Tex Year.
Tax Jurisdiction:
Township:
Owner
Account Number:
Name:
Mailing Address
Legal
Physical Address:
Legal Description. l:
Zoning:
Plat Cabinet:
Slide:
Pennits
Permit Date Permit#
21-SEP-15 12126
Recorded Transaction
Dale
Book
05-AUG-15
4526
30-JUN-08
3436
1 Y-APR-99
1497
29JUL-87
564
21-MAR-55
198
Description
oZ
CITYNAME: WEST ENO
D0038700/858212955963
REAL
2016
A:
07: MCNEILL
97012987
LILY COMMERCIAL, LLC
255 GRANT STREET
WEST END NC 27376
US HWY 1
SHAW LOTS-11
I
Purpose
WELL
Page
Sale Price
484
662,500
582
621,000
too
0
253
0
527
0
OpenfClosed
validity Code
DA
NBHD Code / Name:
731 :
Class:
CV: COM VACANT
Land Use:
COO: COMMERCIAL VACANT LAND
Living Units:
0
Topography:
1: LEVEL
Location:
Parking:
Traffic:
Utilities:
1 ;ALL PUBLIC
Restrictions:
Deeded Acres:
15
Calculated Acres:
20.869
VC Notice / VC Data:
R : 09-MAR-15
Valuation
Appraised Land:
237.910
Appraised Building:
0
Appraised Total:
237.910
Deferred:
0
Exempts/Excluded;
0
Assessed Real:
237,910
Personal:
Total Assessed:
237,910
US HWY 1
NBHO: 731
ROLL:REAL
http://icare.moorecountync.gov/careprdIDataletsIPrintDatalet.aspx?pin=0003 8700&gsp=P... 2/26/2016

Moore County, NC Page I of 1
3
PARID:00032671
ARO RD
TOWNSHIP:
CITYNAME; WEST END NBHD: 731
LILY COMMERCIAL, LLC
ROLL: REAL
Parcel
Porto PIN:
000326711058212969185
Rewrd Type:
REAL
Tax Year.
2016
Tax Jurisdiction:
A:
Tovmship:
07: MCNEILL
Owner
Account Number.
97012987
Name:
LILY COMMERCIAL, LLC
Mailing Address:
255 GRANT STREET
WEST END NC 27376
Legal
Physical Address:
ARO RD
Legal Description 1:
WESTERN PORTION LOT 8
Zoning:
I
Plat Cabinet:
Slide:
Recorded Transaction
Date
Book
Page Sale Price Validity Code
05-AUG-15
4528-
484 662,500 DA
30-JUN-08
3436
582 621,000
26-FEB-98
1351
372 0
29-JUL-87
554
255 0
Description
NBHD Code/Name:
731:
Class:
CV: COM VACANT
Land Use: '
C00: COMMERCIAL VACANT LAND
U%ing Units:
0
Topography
1:LEVEL
Location:
Parking:
Traffic:
tltilitiea:
1 :ALL PUBLIC
Restrictions:
Deeded Acres:
3
Calculated Acres:
3.055
VC Notice / VC Date:
R : 09-MAR-15
Valuation
Appraised Land:
45.370
Appraised Building:
0
Appraised Total:
45,370
Deferred:
0
Exempts/Excluded:
0
Assessed Real:
45,370
Personal:
Total Assessed:
45.370
htip://icare.moorecountync.gov/careprdIDataletsIPrintDatalet.aspx?pin=00032671 &gsp=P... 2/26/2016

Moore County, NC
Page I of 1
PARID:00038291
ARO RD
TOWNSHIP:
CITYNAME: WEST END
NBHD: 731
LILY COMMERCIAL, LLC
ROLL: REAL
Parcel
ParlD / PIN:
00038281'/ 859209061301
Record Type:
REAL
Tax Year.
2016
Tax Jurisdiction:
A:
Township:
07: MCNEILL
Owner
Account Number.
97012987
Nam:
LILY COMMERCIAL, LLC
Mailing Address:
255 GRANT STREET
WEST END NO 27376
Legal
Physical Address:
ARO RD
Legal Description 1:
SHAW LOT 8
Zoning:
I
Plat Cabinet:
Slide:
Recorded Transaction
Dale
Book
Page Sale Price Validity Code
05-AUG-15
4528
484 662,500 DA
3WUN-08
3436.
582 621,001) '
26-FEB-98
1351
375 0
29JUL-87
564
253 0
21-MAR-55
198
527 0
Description
NBHD Code / Name:
731 :
class:
CV: COM VACANT
Land Use.
COO: COMMERCIAL VACANT LAND
Living Units:
0
Topography:
1:LEVEL
Location:
Parking:
Traffic:
-
Utilities:
1 : ALL PUBLIC
Restrictions:
,
Deeded Acres:
3
Calculated Acres:
3.OB1
VC Notice I VC Dale:
R : 09-MAR-15
Valuation
Appraised Land:
45.750
Appraised Building:
0
Appraiser) Total:
45.750
Deferred:
0
ExemplslExcluded:
0
Assessed Real:
45,750
Personal:
Total Assessed:
45,75D
http://icare.moorecountync.gov/careprdIDataletsIPrintDatalet.aspx?pin=00038291 &gsp=P... 2/26/2016

Moore County, NC Page I of 1
PARID;00037476
TOWNSHIP:
LILY COMMERCIAL, LLC
Parcel
ParlD / PIN:
Record Type:
Tax Year.
Tax Jurisdiction:,
Township:
Owner
Account Number.
Name:
Mailing Address
Legal
CITYNAME: WEST END
000374761859209062586
REAL
2016
A:
07: MCNEILL
97012987
LILY COMMERCIAL, LLC
255 GRANT STREET
WEST END NC 27376
Physical Address:
ARO RD
Legal Description 1:
SHAW LOT 7
Zoning:
I
Plat Cabinet:
Slide:
Recorded Transaction
Date
Book
Page Sale Price
Validity Code
01-JUL-15
4512
575 150.000
DA
31-JAN-14
4318
431
DC
27-OCT-86
552
369 0
Description
NBHD Code / Name:
731 :
Class:
CV; COM VACANT
Land Use:
C00: COMMERCIAL VACANT LAND
Living Units:
0
Topography:
1: LEVEL
Location:
Parking:
Traffic:
Utilities:
1 :AU. PUBLIC
Restrictions:
Deeded Acres:
6
Calculated Acres:
6
VC Notice/ VC Date:
R : 09-MAR-15
Valuation
Appraised Land:
89,100
Appraised Building:
0 1
Appraised Total:
89,100
Defamed:
0
Exempts/Excluded:
0
Assessed Real:
89.100
Personal:
Total Assessed:
89.100
1
ARO RD
NBHD: 731
ROLL:REAL
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Moore County, NC
Page I of I
PARID:00032672
TOWNSHIP:
LILY COMMERCIAL, LLC
Parcel
ParID / PIN:
Record Type:
Tax Year.
Tax Jurisdiction:
Township:
Owner
Account Number:
Name:
Mailing Address
Legal
Physical Address:
Legal Description 1:
Zoning:
Plat Cabinet:
Slide:
Recorded Transaction
Date
Bock
05-AUG-15
4528
30-JUN-08
3436
20-FES-98
1351
05-APR-88
598
29-JUL-87
564
Description
NBHD Code / Name:
Class:
Land Use:
Living Units:
Topography:
Location:
Parking:
Traffic
Utilities:
Restrictions;
Deeded Acres:
Calculated Acres:
VC Notice / VC Date:
Valuation
Appraised Land:
Appraised Building:
Appraised Total:
Deferred:
Exempts/Excluded:
Assessed Real:
Personal:
Total Assessed:
CITYNAME: WEST END
0003267218592091)fiB258
REAL
2016
A:
07: MCNEILL
97012987
LILY COMMERCIAL, LLC
255 GRANT STREET
WEST END NC 27376
VALLEY VIEW RD
SHAW LOT 5 NORTHERN 1/2
Page
484
582
372
282
253
Sale Price Validity Code
662.500 DA
621,000
0
0
0
731:
CV: COM VACANT
COO: COMMERCIAL VACANT LAND
0
1: LEVEL
1 :ALL PUBCIC
2.5
2.607
R : 09-MAR-15
38.710
0
38.710
0
0
38,710
38.710
u
VALLEY VIEW RD
NBHD: 731
ROLL: REAL.
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Moore County, NC
Page I of I
PARID: 0003829.2
TOWNSHIP:
LILY COMMERCIAL, LLC
Parcel
ParlD / PIN:
Record Type:
Tax Year.
Tax Judsdiction:
Township:
Owner
Account Number.
Name:
Mailing Address
Legal
CITYNAME: WEST END
00038292/ 859209087144
REAL
2016
A:
07: MCNEILL
97012987
LILY COMMERCIAL, LLC
255 GRANT STREET
WEST END NC 27376
Physical Address: VALLEY VIEW RD
Legal Description 1: SHAW PART LOT 5
Zoning: I
Plat Cabinet:
Slide:
Recorded Transaction
Date
UWK
Page
Sale Price Validity Cade
05-AUG-15
4528
484
662,500 DA
30-JUN-08
3436
582
621.000
26-FEB-98
1351
375
0
05-APR-88
598
280
0
29JUL-87
564
253
0
Description
NBHD Cade / Name:
-. 731 :
Class:
CV: COM VACANT
Land Use:
C00: COMMERCIAL VACANT LAND
Living Units:
0
Topography:
1:LEVEL ,
Location:
,
Parking:
,
Traffic:
Utilities:
1 :ALL PUBLIC
Restrictions:
Deeded Acres:
2.5
Calculated Acres:
2.582
VC Notice / VC Date:
R :09-MAR-15
Valuation
Appraised Land:
38,340
Appraised Building:
0
Appraised Total:
38,340
Deferred:
0
Exempts/Excluded:
0
Assessed Real:
38.340
Personal:
Total Assessed:
38,340
VALLEY VIEW RD
NBHD: 731
ROLL: REAL
http://icare.moorecountync.gov/careprdIDataletsIPrintDatalet.aspx?pin=0003 8292&gsp=P... 2/26/2016
0

Moore County, NC O Q Page 1 of I
PARID:00032842
TOWNSHIP:
CITYNAME: WEST END
LILY COMMERCIAL, LLC
Parcel
ParlD I PIN:
000328421859209055991
Record Type:
REAL
Tax Year.
2016
Tex Jurisdiction:
A:
Township:
07: MCNEILL
Owner
Account Number:
97012987
Name:
LILY COMMERCIAL, LLC
Mailing Address: 255 GRANT STREET
. WEST END NC 27376
Legal
Physical Address:
Legal Description 1:
Zoning:
Plat Cabinet:
Slide: ..."_. _
..
Recorded Transaction
Date
Book
05-AUG-15
4528
3D-JUN-08
343B
20-FEB-98
1349
05-MAR-79
444
Description
NBHD Code! Name:
Class:
Land Use:
Living Units:
Topography:
Location:
Parking:
Traffic
Utilities:
Restrictions:
Deeded Acres:
Calculated Acres:
VC NoticeI VC Date:
Valuation
Appraised Land:
Appraised Building:
Appraised Total:
Deferred:
Exempts/Excluded:
Assessed Real:
Personal:
Total Assessed:
VALLEY VIEW RD
SHAW LOT 4
Page
484
582
374
316
Sale Price
662,500
621,000
0
0
731:
CV: COM VACANT
COO: COMMERCIAL VACANT LAND
0
1:LEVEL
iflal��l�Rl�[q
5
5.191
R : 09-MAR-15
77,090
0
77,09D
0
0
77,090
77.090
Validity Code
DA
VALLEY VIEW RD
NSHD: 733
ROLL: REAL
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Moore County, NC Page 1 of 1
PARID:0003284I
TOWNSHIP:
LILY COMMERCIAL, LLC
Parcel
ParlD / PIN:
Record Type:
Tax Year.
Tax Judsdiction:
Township:
Owner
Account Number.
Name:
Mailing Address
Legal
Physical Address:
Legal Description 1:
Zoning:
Plat Cabinet:
Slide., -
Recorded Transaction
Date
Book
05-AUG-15
4528
30.JUN-08
3436
20-FEB-98
1349
05-MAR-79
444
Description
NBHD Code / Name:
Class:
Land Use:
Living Units:
Topography:.
Location:
Parking:
Traffic:
Utilities:
Restrictions:
Deeded Acres:
Calculated Acres:
VC Notice I VC Date:
Valuation
Appraised Land:
Appraised Building:
Appraised Total:
Deferred:
Exempla/Excluded;
Assessed Real:
Personal:
Total Assessed:
CITYNAME: WEST END
00032841/859209053670
REAL
2016
A:
07: MCNEILL
97012987
LILY COMMERCIAL, LLC
255 GRANT STREET
,WEST END NC 27376
VALLEY VIEW RD
SHAW LOT 3
Page
Sale Price Validity Code
484
662.500 DA
582
621.000
374
0
316
0
731:
CV: COM VACANT
COO: COMMERCIAL VACANT LAND
0
1:LEVEL
1 :ALL PUBLIC
5
5.203
R : 09-MAR-15
77,260
0
77.260
0
0
77,260
77,260
VALLEY VIEW RD
N8HD: 731
ROLL: REAL
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Moore County, NC
Page I of I
PAR1D;00037474 _
TOWNSHIP;
LILY COMMERCIAL, LLC
Parcel
Paro/PIN:
Record Type:
Tax Year.
Tax Jurisdiction:
Township:
Owner
Account Number.
Name:
Mailing Address
/0
CITYNAME: WEST END
00037474/ 859209051268
REAL
2010
A:
07: MCNEILL
97012987
LILY COMMERCIAL, LLC
255 GRANT STREET
WEST END NC 27376
Legal
Physical Address: VALLEY VIEW RD
Legal Description 1: SHAW LOT 2
Zoning: I
Plat Cabinet:
Slide:
Recorded Transaction
Date
Book
01-JUL-15
4512
31-JA14-14
4318
27-OCT-86
552
Description
NBHD Code I Name;
Class:
Land Use:
Living Units:
Topography:
Location:
Parking:
Traffic:
Utilities:
Restrictions:
Deeded Acres:
Calculated Acres:
VC Notice I VC Date:
Valuation
Appraised Land:
Appraised Building:
Appraised Total:
Deferred:
ExemptslExcluded:
Assessed Real:
Personal:
Total Assessed:
Page
575
431
369
Sale Price Validity Code
150,000 DA
DC
0
731:
CV: COM VACANT r
COO: COMMERCIAL VACANT LAND
0
1:LEVEL
1:ALL PUBLIC
5
5
R : 09-MAR-15
74,250
0
74,250
0
0
74,250
74,260
a
VALLEY VIEW RO
NBHD: 731.
ROLL: REAL
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Moore County, NC Page I of I
PARID:00037475
_ VALLEY VIEWRO
TOWNSHTP:
CITYNAME: WEST END NBHD: 731
LILY COMMERCIILL, LLC
ROLL: REAL
Parcel
PariD/PIN:
000374751858216949980
Record Type:
REAL
Tax Year.
2016
Tax Jurisdiction:
A:
Tmnstdp:
07: MCNEILL
Owner
Account Number.
`97012987
Name:
LILY COMMERCIAL, LLC
Malling Address.
255 GRANT STREET
WEST END NC 27376
Legal
Physical Address:
VALLEY VIEW RD
Legal Description 1:
SHAW LOT 1
Zoning:
I -
Plat Cabinet:
Slide:
Recorded Transaction
Date
Book
Page'
01-JUL-15
4512
575
31JAN-14
4318
431
27-OCT-66
552
369
Description
Sale Price Validity Code
150,000 DA
DC
0
NBHD Code/Name:
731:
Class:
CV: COM VACANT
Land Use:
COD: COMMERCIAL VACANT LAND
Living Units:
0 '
Topography:
1:.. LEVEL
Location:
Parking:
Traffic
Utilities:
1 : ALL PUBLIC
Restrictions:
Deeded Acres:
5 '
Calculated Acres:
5
VC Notice / VC Date:
R : 09-MAR-15
Valuation
Appraised Land:
74,250
Appraised Building:
0
Appraised Total:
74.250
Deferred:
0
ExemptslExcluded:
0
Assessed Real:
74,25D
Personal:
Total Assessed:
74,250
http://icare.moorecountyne.gov/careprdIDataletsIPrintDatalet.aspx?pin=00037475&gsp=P... 2/26/2016

WELL CONSTRUCTION RECORD
This farm can be used for single or multiple wells
For Imesul Uwe ONLY:
1. Well Contractor Information:
Well ConnacmrName
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit N:
List all applicable well pemite f.e. Co.% Scores Variance, Infection, eta)
3. WeU Use (chcckwell use):
[]Agricultural
OGeothannsl (Heating/Cooling Supply)
OlndustciaFCommeacial
[]Aquifer Recharge
[]Aquifer Storage and Recovary
[]Aquifer Test
OExperimenml Technology
OGeothemml (Closed Loop)
4. Date Well(s) Completed:
So. Well Location:
Facility/Owner Name
Physical Address, City, and Zip
County
OMunicipaVPublic
[]Residential Water Supply (single)
[]Residential Water Supply (shared)
[]Groundwater Retnediation
[]Salinity Barrier
OStormwater Drainage
OSubsidence Control
OTmcer
Facility IDg (ifapplicable)
Parcel Identification No. (PIN)
5b. Latitude and Longitude In degrees/mlmmtes(seconds or decimal degrees;
(ifwcll field, one latllong is sufiiciem)
6. Is (an) the well(s): OPermament or []Temporary
7. Is this a repair to an existing well: []Yes or ONo
Ifthis is a repair, fill out Mown well construction Information and esplain the nature ofthe
repair under #21 remark, section or on the backofthbform.
& Number ofweRs constructed:
For multiple Injection or non -water supply wells ONLY with the some construction, you can
submitoneform.
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22. Certification:
SigranueofCenified WellContmctar Date
By signing this form. I hereby certify that the wells) war (were) constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well C4m1rue0an Standard, and that a
copy ofthir record has been p ovlde i to the wit owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details You may also attach additional pages if necessary.
SUBMITTAL INSTUCI70NS
9. Total well depth below land surface: (fL) 24a. For All Wells: Submit this form within 30 days. of completion of well
Formulriple"/itlist all depths lfdierent(erample-3Qa100'andr@100) construction to We following:
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10. Static water level below top of casing: (fL) Division of Water Resources, Information Processing Unit,
lfwnrer Iml it above coring. we „+" 1617 Mail Service Center, Raleigh, NC 27699-1617
11. Borehole diameter: - on.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12. Well construction method: construction to the following:
(Le. auger, rotary, cable, direct pub, etc.)
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13s. Yield (gpm) Method of test: 24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days ofcompletion of
13b. Disinfection type: Amount• well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department ofEavimomenl and Natural Resources— Division of Water Resources Revised August 2013

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ENR—Envtnronmental Managenrerrt ISANCAC.0100 .+
15A 1\CAC 02C .0105 PEINUTS
(a) It is the finding of the Commission that the entire geographical area of the state is vulnerable to
groundwater pollution from improperly located, constructed, opmted, altered, or abandoned %•ells.
Therefore, in order to ensure reasonable protection of the groundwater resources, prior permission
from the Department shall be obtained for the construction of the types of wells enumerated in Via.
Paragraph (b) of this Rude.
(b) No person shall locate or construct any of the following wells tmtil a permit has been issued by
the Department:
(1) any water -well or well system with a designed capacity of 100,000 gallons per day
:-
(ecpd) or greater;
-a`a
(2) any well added to an existing system where the total designed capacity of such
existing well system and added well will equal or exceed 100,000 gpd;
(3) any monitoring well or monitoring well system, constructed to assess hydrogeologic
conditions on property not owned by the well owner,
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(4) anyrecoveryw•ell;
(5) any well with a design deviation from the standards specified under the rules of this
Subchapter, including wells for which a variance is required.
(c) The Department shall issue permits for wells used for recharge or injection purposes in
accordance with 15A NCAC 02C ,0200.
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(d) The Department shall issue permits for private drinking water wells in accordance with 15A
xA,
NCAC 02C .0300, including private &inking water wells with a designed capacity greater than
100.000 gallons per day and private drinking water wells for which a variance is required
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(a) An application for any well requiring a permit pursuant to Paragraph (b) of this Rule stall N
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submitted by the owner or his agent, In the event that the permit applicant is not the owner of the
property on which the well or well system is to be constructed, the permit application shall contain
written approval from the property owner and a statement that the applicant assumes total
responsibility for ensming that the wells) will be located, constructed, maintained and abandoned in
accordance with the requirements of this Subchapter.
(0 The application shall be submitted to the Department on forms finished by the Department. and
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shall include the following:
!
(1) the owner's name;
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(2) the owner's mailing address and proposed well site address;
(3) description of the well type and activity requiring a permit;
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