GW1-2022-08387_Well Construction - GW1_20220411

Pr=1nt Form";
WELL CONSTRUCTION RECORR.(GV� .i. f: r For Internal Use Only:
1.Well Contractor Information:
Tarrell Benford Graham Jr: APR 11 202? 14.WATRWZONES.
FROM TO DESCRIPTION
Well Contractor Name I
NCWC 2373-A �''' `' ' ' ' '�,;r,49 rt. 80 ft grey sand/clay w/gravel
W, .
NC Well Contractor Certification Number 15.:UUTER CASING foc±ritulh-eased wells OR;UINER'ffai licable
Graham Currie Diversified Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 51 ft- 4 ! in- sch 40 1PVC
Company Name O A1 A
J t6;i1NNER-Gi1SINGOIi RUB1NG "eother ahclosedlbo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.) ft, ft. In.
3.Well Use(check well use): ft, ft. j in.
Water Supply Well:
pPY FROM I TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural DMunicipal/Public 51 ft. 79 ft. 4 in. 30 sch 40 PVC
:]Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) ft. ft. in.
Industrial/Commercial i Residential Water Supply(shared) 18.:GROUT
I[il ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 23 ft- 77 ft' #3 sand Poured
Monitoring Recovery fr, ft.
Injection Well:
Aquifer Recharge oGroundwater Remediation
19.,SAND/GRAVELPACK;ifra licable
Aquifer Storage and Recovery [3 Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology OI Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.:DRILLING'iLOG'attach addtdon'lisheetsttf aecessar;
FROM TO DESCRIPTION calm hardness soil/rock type,grain size etc.
Geothermal(HeatingtCooling Return) I Other(explain under#21 Remarks) 0 ft, 3 ft• yellow sand
4.Date Well(s)Completed:3/15/2022 Well ID# 3 ft- 25 ft. orang @/grey clay
5a.Well Location: 25 ft- 49 ft. orange sand+water
Jerry Rillo 49 ft. . 53 ft, orange sand/clay+water
Facility/Owner Name Facility ID#(ifapplicable) 53 ft. 80 ft. grey sand w/clay mix+large gravel
2013 Cemetery Road, Candor NC, 27229 ft. ft.
Physical Address,City,and Zip - ft ft.
Montgomery 7572-00-71-6794 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer
35 10' 58" N 794413811 W �S-
6.Is(are)the well(s)ox_ Permanent or OTemporflry Signs 'fie d Well Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or i)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If 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 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-1 is needed. Indicate"rOTAI,NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 77 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeltaerent(example-3Qt 200'and 2@100) construction to the following:
10.Static water level below top of casing:44 (ft.) Division of Water Resot!irces,Information Processing Unit,
//'water level is above casing,use'•+ 1617 Mail Service Center,Raleigh,NC 27699-1617
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: 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
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13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniectioti 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.
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Form GW-I North Carolina Department ofEnviromnenial Quality-Division of Water Resources Revised 2-22-2016

Montgomgrg Gbantg fl alth (Dapartim 't
envirommtof flolth SQeflon
2i7 S Main St.
Troy, NCB 27.371
phony A (.910)572-817t)
'tax #:G9it)).571-0912
Well Construction Permit
Permit Number 2021038W Parcel ID, 7572 00-71-6794
_ __....... _-- _
Owner Name Jerr Rillo Ass elated (permits 2021193
__. ..._.....____� ___..._.._. _.__.__......_..._._.
Address 2013 Cemetery Road Phone# 910 6S2 31�69
.............----........................._.-_.._................
Candor, NC 27229
93.1.Addre Cemetery Road
.-_-_.. . .......... ....__..._ . . ....
Subdivision_ Map Phase, Section Lot#k,
I*x•*.
-............ -- _ ---..... _ -
This permit Issubject to dll information provided on the wed permit application. The well must be constructed in accordance with all
state and local regulations by a registered well driller. A copy of this permit must be on site:during construction of this well. A copy of the
well log report shall be submitted to the Montgomery County Environmental Health Department within 30 days after completing well.
Wells must be installed in area _._ .......... _.....—_-_
Site Sketch
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Fla n aV:zheil"
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.........._.___.....__.._.........._..___..........................______....__............_....._.._._.___...._.._....._..____._............_..._....._..___._ __ _. _ _ ______. . _ ___ - __ _
....
_ _____ - ._.___..___ _ .
Conditions, Well to be constructed in ac c ordance with NC Well Construction standards'. Contact MCFH with questions.
_..-.._....._............---------....................._-_......--------_..._..._............................_._.........__.....................................__........_..._.. _..,.......__. _.....
--- -- -._......_......._.........._...._..............................................................._.......................
Grout Depth] 20 ft.
Issue Y W _ 11: ....,._ Date ._.� .,_.__._._..
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(permitlexpires 5 years from this date)
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Montgomery County Health :Departent
Environmental health section G
Applicant Jerry Rillo Pertn.it Number: 2021193
owilel': Jerry Rillo PIN #: 757200716794
Proposed Use:. S.i=R Water. Supply Private
Subdivision or,SR cemetery Rd. Lot#: Section 9: Map#:
IMPROVEMENT PERMIT
System: New Projected.Design Flow: 360 GPD "i-ype of Wastewater: domestic
It of tedroor= 3. ff of Occlapargs: 6 Rasetnent: Yes Basement Fixtures: Yes #of 13tnployees: of Seats:
Proposed Wastewater System Type: Conventional LIAR for initial System: .600 G1)D/Sq.fit.
Proposed Repair System Type: Conventional LTA.R.for Repair System: .600 G D/Sq. 1-t.
IMPROVEMENT PERMIT CONDITIONS: ***SEE Ai"rACHED SITE SKETCH
Permit isstied.f0r 3 13R.tttsidential
InitialandRepair. Conventional.
'Me issilauce oftlis lmpravernenl Permitby'tbe i4lontyz)mery:Coiutty Health Department in no way wnnntees the issuance ofotberpermits "i7,"ieirnit liFilder is ruponsible far checking with
tippropriate.govemiitgbodies mine tingtheirregtiiivnents. 'Il)is peri»it is a site approval for tie ftttureinstallation oPan on-site wastuvatvr system arid is stibieci to revocal ion if the site plans or
intetxted im chmiges.from those sltownalvve orim then Ipr'lication. 11iis Improvement Permit must beai�cotnp:Fhied by a"ostroctioli attiho it itiowpriorto obtaining any buililing permits and
1?diire the'wasteivatartiystetiris are>tallcd Tkiis. pro " etit P [is valid for a period of live years fr an the d*of:issuance unless llherw se";idled.
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Atith.orized State Agent: I)a e
AU I.110R:[ T:ION FOR WASTEWA,rER.SYSTEM C4N'STRITTION
(Required for Building Pertttit)
The cotntnictiiet tntdinstallafirat imquirements of Rd6.195t),.1952,.i954,.195C .1957 .1958,and.1959 of Title l5A.Subrltapter 18A of t:bc 1`ortb Carol ina Adulinkrilive Code are
inwrporated by tetWnce into this.Irrinitaixi shall be met. Systems shillbe ii.rtallfd iu accordance wiili the attached s}stem:layput
Systern: New Projected].3esign,Flow 360 G1')D ***SEE ATTA.CHE'D SITE SKETCH
[).reposed Wastewate,System Type: Conventional
,Proposed Repair System Type: Conventional
Septic Tank: 1000 gallons Pump Tan1c: gallons Trench:Length: .200 feet Max Depth: 30 inches
Trench Width: 36 . inches Trench.Spacing: 9 feet Total Stone Depth-. 121. i.n.ches.Extra Soil Cover: 0 inches
CONSTRUCTION AUTHORIZATION C:ONDI:TIONS:
5�'f tlill'lC bdtLlftd lttia�e In flti.n thin:lS!Itt aVet)n]illtldaty tlas n ent,tilliinbinb..Instnil ni.trill eati(m tlddd On Cn soli:aroa::Con taut 1v1CI'.I.f_with cineiti+)ris.
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This AuUmrizmion G'or Wastewater System Caisinictiai is vaiidlbr a[xricA L(Itinl.to die ptaiod of validity.of tht linpravei ient Wastewater system
consvirtionand insttdiadcin oust meetall conditions andspt lflvatfons its set Ibrih in ale Improvement Penriit,CFnlstructioti Ats.horin,rian,and the attached site sketch with system&(ails.
Construction and.ir>tallationinust alsonteet all requirements set forth in the Rules Governing Snnitti y Stt+vogeC'ollection,Treatnient.And'Dispriml Systems and any other applicable rules
and.til s. (2)Thewiiste),vatersystein slialf.uot lc'coveredorplaeed iniL)%e nntil inspected by the Montgomery Cowity l"lealatD.epattme lit and annpenttisxi.PErntit i 3 uciL 13)Any
altcthtibu ill siie orsoil;Nnditiuns(includiriv lnrlticm of sivcumsand appurtenances)ornnodif oodons in use,+raste+vaterhow,cx wacte+4atvrchanicteristics as specified in.the asso iated
:nrprow:imit Pennit wid application.ntaystihject this AuthorUntion and associated pern)i t(s)to relocation.
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~''Lf a»»licaitilt:i
I understand this Improvement Permit and/or Constrnction.Autharization is different front the original requests on the
relevant aIpplictttion. 1.accept the:specifications of this permit; including the:site sketch.
A.pphcurit/Legal Represents ve Sign' i()itl ei
Authorized.State Agent: Date:` Z �Q
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