GW1-2022-03811_Well Construction - GW1_20220404

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Tarrell Benford Graham Jr. 14.wATDR.•ZONES .. ` k
Well Contractor Name FROM TO DESCRIPTION
NCWC 2373-A 51 ft' 88 ft. orange sand
ft. ft.
NC Well Contractor Certification Number T5r`.OUR?ER,CASING for3nulh'eased wells zOR I INER:ifsa"licatile
Graham Currie Diversified Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 68 ft. 1 4 In' I sch 40 1 PVC
27446 16�INNERCASING.ORTUBING; `eothertnaliclosed=l'oo't
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,Stale,Variance,etc.) ft. ft- 4 in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
_ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 68 ft- 83 fr. 4 i" 30 sch 40 PVC
Geothermal(Heating/Ccoling Supply) (x Residential Water Supply(single) 83 ft. 89 fL 4 in. 30 sch 40 Stainless
Industrial/Commercial ( Residential Water Supply(shared) ;.
18 GROUT:
Irrl ation FROM TO -MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 23 ff• 60 fr• #3 Sand Poured
Monitoring [Recovery ft. ft.
Injection Well:
fr. ft.
Aquifer Recharge DGroundwater Remediation
19 SAND/GRAY=EL'.PACK,if'ia licable i;.
• 3i Aquifer Storage and Recovery I....'Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwatcr Drainage
Experimental Technology l_j Subsidence Control ft. ft.
Geothermal(Closed Loop) f i Tracer 20.DRLL'1 IN.G'LOG`attach additianllsheets=if necessrir
FROM TO DESCRIPTION color,hardness,soillrock e, rain size,etc.
1 Geothermal(Heating/Cooling Return) {.: Other(explain under#21 Remarks) -
0 fr. 2 ft. orange sand
4.Date Well(s)Completed:5/29/2021 sell ID# 2 ft. 18 ft. re (sand/ clay
5a.Well Location: 18 ft. 51 ft. oran a sand/clay
Mark York 51 ft. 88 ft. orange sand
Facility/Owner Name Facility ID9(if applicable) 88 ft- 101 ft' gray;hard clay
3704 Youngs Road, Southern Pines NC, 28387 ft. ft. j
Physical Address,City,and Zip ft. ft.
Moore 00054696
County Parcel Identification No.'(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) Cea'tirleation:
35 10' 31" N 79 21' 55" 9 f
6.Is(are)the well(s) Pcrmanent or [Temporary ignature ofCe to ell C�Xtor �Date
By signing t is ereby certify that the wells)eras here)consm ucled in accordance
7.Is this a repair to an existing well: E3Yes orBNo with ISA NCAC 02C.0/00 or ISA NCAC 02C.0200 Well Construction Standards and that a
Iflhis is a repair,fill out known well construction htforntation and explain the nalure ofthe copy ojUris record has been provided to the well owner.
repair under 412/remarks section or an the back ofthis 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 I GW-I 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: 96 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For medtiple welis list al/depths ifdii feren!(example-3@200'and 2@/00') _construction to the following:
I
10.Static water level below top of casing:37.7 J7_ #f. Division of Water Resources,Information Processing Unit,
Ifwaler level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
APR - 4 2023 ''11.Borehole diameter. 7.5 (in.) -24b.For Infection Wells: In addition to sending the form to the address in 24a
Mud and Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: r.u+ casrnTt^y1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) °'" ' p
n 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 Supply&Infection 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 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
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