GW1-2022-03153_Well Construction - GW1_20220222

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W1LLlu t.VIN31AU1.11V1V l(Lk—U! J (lT W-11 I Por internal use my:
1.Well Contractor Information: Ill
Tarrell Benford Graham Jr. 1411WATER,10NES
Well Contractor Name FROM TO DESCRIPTION
NCWC 2373-A
ft. ft.
NC Well Contractor Certification Number 15.:OUTER,CASING for multieased,wells,OR:IiINER if a I livable
Graham Currie Diversified Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 f. 63 ft• 4 � i" sch 40 JPVC
202 O25W I6.INNER-CASING<OR`TUBING_ af eothermelosel=loo '.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State, variance,etc.) 63 It- 73 ft. 4 in. sch 40/30slot PVC screen
3.Well Use(check well use): in.
1Z:SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
AgriculturalMunicipal/Public 73 ft. 78 ft. 4 ' '"' 30 sch 40 Stainless
Geothermal(Heating/Cooling Supply) x Residential Water Supply(single) 82 ft 87 ft• 4 '"' 30 sch 40 PVC
Industrial/Commercial OResidential Water Supply(shared) 1g GROUT
Irrigation ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 23 ft• 95 ft• #3 sand Poured
Monitoring E311ecovery
Injection Well:
Aquifer Recharge Groundwater Remediation
s 19:SANn%GRAVEL PAGK if a 'livable'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) DTracer 20.."I)RILLINGLOGr attach additonalsheets:ifnecessa
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
(Heating/Cooling Return) Other(explain under#21 Remarks)
RGeothermal p rt. 4 rt. yellow sand
4.Date Well(s)Completed:10/7/2021 Well ID# 4 ft. 18 ft• orange/grey clay
5a.Well Location: 18 ft 33 ft orange sand/clay
Marilu Leyva Hernandez 33 rc. 78 rt. orange sand/clay mix
Facility/Owner Name Facility ID#(if applicable) 78 ft. 82 ft. orange sand/clay
402 Blake Road, Jackson Springs NC,27281 82 87 or sand
Physical Address,City,and Zip 87 ft. 95 ft• orange sand/clay
Montgomery 7584-07-57-2752 2l:<REMARKs _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) Q //JJ 22.C ati
75
N / d , /J''7 w
6.Is(are)the wells)Ix Permanent or OTemporary Si attire of Certified o Date
By sr 01711, ere I that the well(s)w s•(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ]No it /SA NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 of this fonn.
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 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 24a. For All Wells: Submit this form within 30 days of completion of well
For untltiple wells list all depths ifdierent(example-3@200'and 2@100') Construction to the following:
10.Static water level below top of casing: �1 ( (ft.) Division of Water Resources,Information Processing Unit,
lfivater•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 Resour�es,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& Injection 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 of Environmental Quality-Division of Water Resources Revised 2-22-2016
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mont8o=rg Coung fiI¢alth 9opartmQnt
Environmizntal fIiz,alth S¢etion
2176 Main R
`frog, NC,2M
phon¢#: (910)572-W5
Well Construdion.Permit
Permit Numbed 2021025W- Parceil 7584 07-57-275.2
Owner Name Marilu Leyva Hernandez Associated Permitsd) 2020024
Address PO:Box 746— Phane#r. 910-975=0040
Candor, NC 27229
911.Address 402 Blake Rd. —
Subdivisiori Belle Acres Map[Phase Section: _Lot#_.
'This permit is subject to o//'information provided on the well permit application. The well must be constructed In accordance with all
state and local regulations by 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 Heath Department within 30 days after completing well.
;Wells must be installed in designated area.
Site Sketch
P)O
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Conditions�_..� Well to be constructed inaccordance with NCW�II Construction Standards.)Maintain all required setbacks
shown.on permit illustration.
Grout Depth 20 —_ft.
Dade;
- (permit expires5 years from this date)

nvtro mnr ota4 ll a iom ,
Vtlrett onstruc ianP rm
Pert Nul lb r Q21_A25W arc l CL� 7584 07 57 2752
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owner ame Madjp' Geyv hernandez l�ssow:rated t?rmrt.c 020024
PA:BoX�46
�nanh# '�.�0�75 At)4t�.
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si bdtv 1pn Re Acres, pfPnas� 5ectipn i tot
*This hermit is sab e<t To,aN rrifarmatron provlaeil nri x12e !elf p It tr.'t appllcgtton l7ae well must be constivaed!, c ccordonte;tvith Wl
��trtte arrc!'lcccri reg� ottaris:tiytx rec�ister�d:well d 11 r i copy of this rerrnit nnist,be nt!s to doting construr~tiorr.ttf tli s.hrei,. A:cfO of the f
iwrll'.lo r r�rt rtruG b ;sc drvtitted.tp:tf�e It tontgon�ery ocitatyErrv`irvnmehatd We�rlfla,D.e. �r�rnent withirj°3Ci a.tyys after rt mpietri�9 tuelt
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iWeflsmttstbeMstolfedindes/ note orea:
� _ SiteSketch:
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onc3rtlon j'bV It to Fie:construci:ed its accordance�w th htC k`Je(I Go(istruction Skar lords Nlainta ri all re�uired setbacks
ssho�.�rn o.r�°�Serml��{lusfiraticin: �
Grc�t.l eptll 26 Ft
nit:ezpires.Svecrsirem this date} .
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