GW1-2022-03152_Well Construction - GW1_20220222

WLl LL 11,V114311 ull—liyIN 1i1Ll.%J" (lt W-11 i or internal use unly:
1.Well Contractor Information:
Tarrell Benford Graham Jr. 14 WATER.ZONE-S 1 i
FROM TO DESCRIPTION
Well Contractor Name
NCWC 2373-A ft. ft.
ft. ft, j
NC Well Contractor Certification Number 15.OUTER-CASING'for multi-casd&wd1s.^OR LINER if a licable
Graham Currie Diversified Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft 63 ft- 4 1 i" SCh 40 PVC
Company Name 02 02��
16.INNER:CASING,OR'TUBIN�,; eothertnaLclosetl-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permils(i.e.UIC,County,State, Variance,etc.) 63 ft. 73 ft. 4 '" sch 40/30slot PVC screen
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public 73 ft. 78 tt. 4 in' 30 1 sch 40 IStainless
Geothermal(Heating/Cooling Supply) ;x!Residential Water Supply(single) 82 ft. 87 it. 4 in. 30 sch 40 PVC
Industrial/Commercial E3Residential Water Supply(shared) 18.13RGUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 23 ft. 95 ft- #3 sand Poured
Monitoring DRecovery
Injection Well:
Aquifer Recharge DGTOundwater Remediation 19::SA'NDIGRAYELP?iCK-i£a�'^'!� ficable`
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20-DOULLING-LOG:attach.addition aPsheets if necessau;
FROM TO DESCRIPTION color,hardness,soit/rock type,grain size,etc.
Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) 0 tt. 4 rt. yellow sand
4.Date Well(s)Completed: 10/7/2021 Well ID# 4 rt. 18 tt. orange/grey clay
5a.Well Location: 18 fr' 33 ft' orange sand/clay
Marilu Leyva Hernandez 33 er. 78 fr. orange sand/clay mix
Facility/Owner Name Facility ID#(if applicable) 78 tt• 82 fr orange sand/clay
402 Blake Road, Jackson Springs NC,27281 82 ft. 87 ft. orange sand
Physical Address,City,and Zip 87 ft- 95 ft orange sand/clay
Montgomery 7584-07-57-2752 21.,REMARKS -
9 rY
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: FEB 22 9
(if well field,one latHong is sufficient) d 22.C ati t
t rll raw A
6.Is(are)the wellLx.$) Permanent or Temporary Si attire of Certified o Date
By st rm,.0I0 ere fy that the well(s)w s(were)constructed in accordance
7.Is this a repair to an existing wwell: Yes or 9No a 15A NCAC 02C 0 m I SA NCAC 02C.0200 Well Construction Standards and that a
Ifthis•is a repair,fill out latown 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 of this forms. -
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 1 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: 92 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
por multiple wells list all depths ifdiiferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 'e �t ( (ft.) Division of Water Resources,Information Processing Unit,
If 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
13a.Yield(gpm) Method of test: 24c. For Water Supply&Iniection 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 2-22-201 G

Mont8omag County fl7mlth 'D partmFnt
ebvironmizntal fiQeilth Sizction
2175Main 5t.
Tray, lic,9-7 71
)?Bone#: [phone]
WeU:Construction.Permit
Permit Number 2021.025W_ � ParceliD:j 758407-57_275.2 --_---
�~ Associated Permits:'iI 2020024
Owner Name Marilu Leyva Hernandez
_.
_Address PO Box 746 Phone#: , 910-975-0040
Candor, NC '27229 _
911 Address` 402 Blake Rd.
Subdivision Belle Acres _ Map/Phase Section' Lot
***This permit is subject to all information provided on the well permit application. The well must be constructed in accordance with all
state and local regulationsbya registered well driller. A copy of this permit must be on site during constructlon_ofxhis well. A copy of the
well log report shall be submitted to the Montgomery County Environmental Health:on
witLln 30 days after completing well.
LWells_--^_mustmust be_installed,in desjgnnated:area.__
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Site Sketch
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CdnditiQRs:...]1 well to be constructed in accordance with NC.Wpll Construction Standards: Maintain all required setbacks
shown.on permit illustration.
Grout Qepth v20 _ ft.
Isued s Bv.:_ (�bt.-'�'i
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(permit expires5 years from this date)

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' tn:te orac),Iccal regz lnftatix:byi 6 regist&r d:well tllcJfi r: A+apy of ih►s permrt ri i5t be r2rr 3 to durrni�constructiUn of tlrfit wel, A:: bpy pf tlir
11"l0 r ic�rkytrull b ;s bn7itted.tp:the lytorrtg©n7ery oc�ntyErrGirvrt mentalHeir/flt Lt ptar�rnent wr4hr`r}30 days after rtan>pietrny.iveN.
3lhfeils v, t, installed in dell na.t d area: —
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orrdatlan� ��veli to bye canstrucike6ih accordancery ;th�3C~Vile((-Goiistruction Sta lards i Maintain all rtgUtred setbacks
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1pb:mit.'Wres's vearrirom this date}

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