GW1-2022-08385_Well Construction - GW1_20220426

^{:Print Form _
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Tarrell Benford Graham Jr. 14VATER'ZONES ..
Well Contractor Name FROM TO DESCRIPTION '
NCWC 2373-A ft.
ft. ft.
NC Well Contractor Certification Number 13.OUPERcCASING;for"muld:cased wells)'OR;.[INER<ifa licalila "
Graham Currie Diversified Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 66 ft. 1 4 In. sch 40 JPVC
2021014W A&INNER=CASINGsORTUBING` '"eothecmakclosed=loti
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS I MATERIAL `
List all applicable Nell construction permits(l.e.UIC,County,State,variance,eto.J ft. ft. In.
3.Well Use(check well use): ft.
ZWatcrSupplywell:
FROM TO DIAMETER SLOT SIZE THICKNESS MAT
ERIAL
HAgricultural E)Municipal/Public 86 ft. 86 ft. 4 in. 30 sch 40 jPVC
Geothermal(Heating/Cooling Supply) IRResidential Water Supply(single) ft. tt in.
Industrial/Commercial Residential Water Supply(shared) LS +c1zOUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 23 ft• 66 fl• #3 sand Poured
Monitoring DRecovery ft. ft.
Injection Well:
ft Aquifer Recharge }Groundwater Remediation ft.
TACK
Aquifer c
Aquifer Storage and Recovery 138alinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test 0StormwaterDrainage ft. ft.
Experimental Technology. OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 3pDItILLINGLOG ittich aildItionaLshetlts;tfnecessar
Geothermal Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/mck a rain size,etc.
0 If, 4 f�• . yellow sand
4.Date Well(s)Completed:3/25/2022 Well ID# 4 ft. 23 ft. orange sand/clay
So.Well Location: 23 ft- 61 f'' yellow sand +water
Gary Welch Sable Lane 61 ft. 1 83 ft, yellow/orange sand w/clay mix+water
Facility/OwneiName Facility ID#(ifapplicable) 83 ft- 91 ft. Brown
PO Box 10 Norman NC, 28367 ft. ft.
Physical Address,City,and Zip ft. ft.
Montgomery 7583-00-36-7884
-a
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. ton:
35 13' 14" N 79 43' 22" V 2s,/
6.Is(are)tliewell(s) Permanent or Temporary Signatur fie , e on actor ate
y signing this jornt,1 hereby cerl that the well(s)was(ire onstrucled In accordance
7.Is this a repair to an existing well: n+Yes or No with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
IjNds•is a repair,Jill out known spell construction Information and explain the nature ojthe copy ofthis record has been provided io the well owner.
repair under 921 remarks,section or on the back ofthis form. 23.Site diagram or additlonal 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 TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well;depth below land surface: 89 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple spells list all depths ijd1JJeren!(example-3 r@200'anr12(a31001 construction to the following:
10.Static water level below top of casing:42 (ft.) Division of Water Resources,Information Processing Unit,
Ij)vater 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 Rota above,also submit one copy of this forin within 30 days of completion of well
12.1Ve11 construction method: Rotary 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 Centers 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 ow-1 North Carolina Department ofEnviromnental Quality-Division of Water Resources Revised 2-22-2016

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