GW1-2022-08386_Well Construction - GW1_20220411

Prirlt Form` s,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Tarrell Benford Graham Jr. 14.WATER'ZONES
FROM TO DESCRIPTION
Well Contractor Name
90 ft. 91 ft' crackingfrock
NCWC 2373-A
201 fl• 202 ft. cracking rock
NC Well Contractor Certification Number 15S OUTER CASING for multi-cased wells OR LINER if a licable
Graham Currie Diversified Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 74 ft. 4 i" sch 40 JPVC
Company Name 94�
16 INNER CASING OR TUBING edthermal close drloo E
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.VIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): fr. ft. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER i SLOTSIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) x Residential Water Supply(single) ft. ft. in•
Industrial/Commercial DResidcntial Water Supply(shared) 18:GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 23 ft• hole plug Poured
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAY L PACK if applica$le
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer -20.DRILLING LOG attach additional,sheets if'necessa
Geothermal(Heating/Cooling Return) s Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
0 ft• 28 ft• orange clay and slate
4.Date Well(s)Completed:3/22/2022 Well ID# 28 ft. 39 ft. Blue Slate
5a.Well Location: 39 ft, 302 ft. Blue Rock
Joey Jernigan fr. fr. -
Facility/Owner Name Facility ID#(if applicable) ft. ft.
AFH
184 Grey Fox Road, Ellerbe NC, 28338 ft. ft.
Physical Address,City,and Zip ft. ft. I(✓lJ\14
Richmond 746900740068
21.=REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iattlong is sufficient) iiviihl5ANCA5CO2C.0100or4l3ANCACO2C.020
35 06' 16" N 79 46' 45"
6.Is(are)the well(s) Permanent or Temporary on ctorEWell
e
ere y certify that the constructed in accordance
7.Is this a repair to an existing well: DYes or x)No 0 or/3A NCAC 02C ction 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 of this 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 TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 302 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2©100') construction to the following:
10.Static water level below top of casing:42 (ft.) Division of Water Resources,Information Processing Unit,
Ifuater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 7.5 (in.) 24b. For lniection Wells: In addition to sending the form to the address in 243
Mud /Rotary and air 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.)
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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"Oi;<-00nstructlo*n Perm t F r 0U. -b44 -. 11 `
" t Richmond County lie,
*CD Department I.
*CDP file Nt.trnbev 265948
127 Carblibe.,Sbael I
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RorkinghICAM NC 2M.79 r aax Lot Tax €�(bC1.9:
Phone:[phone]a;-; (910.)907.8372 Evaluated For:VVE:LL
PERM,It VALID UNTIL: 01612023
Atvperty0t il9r: Joey Jernigan y A plicant .la jrJernigan �\
AddMss: 184 Grey Fox feel Mdress:, A84,Groy.Fox Rd
Cay: Cllerla i v: Plate
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state Zip: NC- _- 283a£3 1 Statelzip: NC . 28338
Phona#1: �910) �it52-55'.57 Pholie i; {91 ) 5 2- 557
fir. : :_ oal if.nA Mie Ir;fori�'t��6.t<t1
d'dfassYRoad 1 - �ubd vision. Rankin l-i ke f�hasa; ^� 1_ot: 18
184.Grey Fox..�sl _
`Propost d.use of Well-, rvtoiderntial
E((erbe iC +3338
L"atittt�.� .
Longitude _ t'Ptili3;3
Sits Addtess.184 Grey cl;,Rd Direeiittrl5:Hwy 7:i `dcf!Elferbe.1'FlVernon White fit:.
'�IR second Or f=qx� then beer left lot on righi
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Well,Cootractoir Ityrormoon
Drlilrng L'e�t+tractar � Drilk<rt f��gistraYlart
Aj ij,�1.�
Permit Conditions
"i�e.iiYiit Corldiil0l?s
New.vlotl must ho 111 JAW",t,t ri irimum from oil iwllqinp pori r..tier,.indwring attnchod_porchos"Old
dafts.
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Well locati.Yn,corrstrucilon and.procection must invet.all eslafe and:iocA, guiavons acid mist be inspectc7 ani9 F pprcvw by an aulbodzed repTisenVAlve of
the Lecal:tienim Department.The permit may oe revciimd atanytimeforfailure to comply?vrittt r-gurt 16ris.The siting or apt=ovad-rfdl ccnsGu_tior.
&eea(Sj Dy ill*-Health Oepasiment is to provide pro:ectiontrom the Max ,loia sources of conlanllnation.!Tile approvrw:xell area isi may not Ce change`
wiihotR pemtlssluntrom anauthoriz i r pr�en:ative.pf the Gael Hea'prvik4 admeni.inn volume of quality of veater is guarantead by the Health
2001 t iANC�ICK,6RY 1 r ' , Issue" t 1 i
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IMPROVEMENT PEIR IT far;�T##tci�l�s .13r �a"�'�et 0121
Richmond Courlty'ri,ralth Department
,Cbt'rlia t�u:tlbet I 266t - l
t�OUlltl }L�`4�Slltii�i6'i:
NEW
£valLiatcd ForC. Rockingham WC 28379
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t + PER 7 1WO ATIL 1 $ (y 3
Phone:(910.)N7 Ct3?t7 N {010)�997-83r2 -
IF C.
NOTE TOINSAECTIONS DIVISION Bylldlptl P@,nlis to nV De lssow r"11h G:il scrim rovement P�nilit � � ti)GA7
Appupani: Joey jonilgarl - -� Y / Property OFvner. JCtlq Jertrt{�ri
Address: 100 Boyultu >l 100280yatle Si
H d-dte:ro:
City: Hc3ttiiol 6;ily kiarnlet
statolzip: iv4 ?Pi til5 $tat0; ip: NC 26345
Phone >: (910)5824057 phone (Jt0i SLtP hfi57
utld.ri;sS9»'�ir:3r+�yFox.k'ci 'Lfii3��.ncultar Y4 S[igl4lgrntntibn `'�
Road :Elterlia blC 2W3131 SwANIston: Minkin Lako Phnso; Lot: tis
Township:
=p44¢+lA
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Structure: SINGLE 5riNNLY Hwy 7;3W of Elletbe,7'ANe moti'Milite Rd.TA second Gray t ox,!lien
iF at QOdrobms; .3 bow left lot on:tight II
�at Paopla: 2 `
nWater Supply: NctNbV.8l.L
_ inifTat Svs.tK.m; � w• --- rk1�.���sc3fr.1tTd2tx �,
"Site CiessfieQtion.- Provissanopy E�frik,[is -
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ar r
EaPro[ite system? OYes. .)i`:0 Iininiii Trench ilAgth Inches
Derlgp Flow: (�
irl2XltiruniTiEnCh"De.p''1?: c�, 4. !!lines
Soll Group:
fiil Depth, torches
soil Application Rate: pJ 3 Saptie T a a Gallons
n'r,: f�
"x stem C:Ir�ssiFicatronfD'~sc;rl ttoo: �.._.. —.•.--_:�_.—_�
Y Purd:p Required': eve ldo 0itsy Ee r,..3quirec
"rYPr<it A.COW 5Yb1'�t,r1.(SIiJr.>t:k;;-t:'!�A9tt:Y OR013 C>PL?f�72
(ES71 ftmP Tank: Gallons
`Propased System.25%REDUc l0N
Repair 'ysteni.ft,aglrtr d: OYos ONO G NO ibiit haS Availus,fe Space ~F—
'•.St,,g C ft i
a Ftrovi�iorYcill .Srtitairl, ii:ipirownTrench Oe,Pttt: M T, inCnBa
Site Classc:8von: y
$nil application:Rate; 0 3 5 hi mimuni Trench Depth, 4 Inches
"SS(StG'tli 13S5f0tititlll?sSf.i I(1t10:f1:
Depth; 1t5T:t±°r
'l PE 11 X CONV S1 STOA(-8f N�(;:i 4FAi,A1.wY OR 40( (yYp OR
Less% PumpitequireC; '.)yes 0N.0 () `r ceRsquited
"Proposed System: 2r)'.,RLiD CTION
'Pump 7ant:: _ 4srio." �1
�No grading or construction vetiviV is allowed in arc:3s daslghated tOt Ysderst and repair without a.r)proval Of Hedth Oel)Wia?ent. F.
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^Tltt`fAo+!!'tir:aitIItiS
The Issii6nrcr o1 tMis owmit by ftaa:Itaalltig6paatin ni in no way giu3rsntsed the iszuanco of other pefr ils.The perntlt midst'
is re:xporisible for cherking with their requirements =�
^I�GYAnii G aRct ld.o_p;, Consult.or!slier Ixfor to lo5f ilialfon to ton.UW'p prour galrltn t1IEUdrimllii Otiiilcd rviOXV SMI fOr this tpl.
'PitaDepartnir:tit and Local HaaltnMp8tltrii 1 may Impose conditions•on thalssuanceandmqrevakathepErmltsforfanuraofthFsystemto
satisfy the c.ornlitions,•Gierulss,or.this article Th.
ls perWt Is sutr)i ATO t'oVocat�fP�11the site plant,pia,~or•Intandsd usaoYr-Any*s(NCGS 130Av36
(q).7gs.person owning or controlling trio system.shalt be responsible for as•d"ri g vNii.pilancewith the tWp%ruTCS,and periiilt conditions
regarding.systettt location,irtstallatioli,operation, i otitenant e,monitoril)o, and repair
"`Authorizes) State Ayer%:2()c1-HANCOOG ,BRYAW ✓' �'r ;� his of issue, ,1. •43 1 6 l a 0 J 8
OvYner/A plicanl.Signatur3:_
Ay Sj%%Pia'rilDrawing pt£acfted:—