GW1-2021-00406_Well Construction - GW1_20210129

WELL CONSTRUCTION RECORD for Internal use ONLY:
I his litrnt can be used for sinsle or nulliplc wells
14.NVATER ZONES
I.NN ell Contractor Information:
FROM TU DESCRIPTION
Sammy Rackley ft. ft.
1,.II Contractor Nano ft, ft.
35 73-A 15.OUTER CASING(far multi-cased wells)OR LINER(it applicable),
Ni 1\ell Contractor C crtillealion Number PROM I-t/ MAML1 LR THICKNESS MATERIAL
Lake Valley Well Co., Inc 0 ft. 48 ft 6.25 rrr .188 Steel-galvanized
l'tnnpanv Name
ft. ft. i n.
16.INNER CASING OR TUBING(geothci(mal cla ect loop},
2.NN ell Construction Permit#: E20 001450
FRilv'I TO DWNIFILR TIIICKNEiSS MA1ERIA1..
:.Ippil,ohir a-i li rnnH7'nrlinn P,vinill,nC I ,uuui,.9,11r. I rl, ft. ft. in.
3.NN ell I se: ft. ft. in.
17.SCREEN
I W AI 1'0 T[[R TI IICKNLSS SLOT SIZE MATERIAL
Residential ft. ft. in.
ft. ft. in.
18.GROUT
FROM TO MATERIAL CMPI...AC'EMEN'i ME FHOD K AM6l1N 1'
0 ft. 2 ft, Concrete 1 Grouting Through
2 ft- 47 ft, gentonite slurry 9 Tremie Pipe
fr. ft.
19.SANDIGRAVEL RICK(ifa[rplicable).
PR(7M TO MATLRIAI I.MPIACEMF.NrMLTHODK AM011NI
ft, ft.
ft. ft.
1. Date NN elf(s)Conipleted: 1/20/2021 N1 ell ID#
It. ft.
Sa. N1 c11 l.ocutit'°' 20.DRILLING LOG(attach additionalshects if n&essar9�
a,vnnl/,,v non,n,'( orvn11-Sl w, I{.ir i,utc:�.Ch FROM TO DLSCRII I ION(color,hardness,soil/rock type,:ram size,etc)
Hector Valencia 335764 0 ft, 38 ft, Orange Clay
I aiuht\ tr„nar Njme f,aciht) ID(it apphcrhle) 38 ft. 420 ft. Gray Rock
19 E Hillardston RD Nashville 27856 Lot ft. rt.
Pill Swill Addre,,i•C'itY,and Zip ft. ft.
Nash 381600791392 ft. it.
l,ounh, PaieCl ldenlitica;itm No.,N.N) ft. ft.
51). Latitude and longitude degrees'nditutesiseconds or decimal degrees:
f well lield.one lat lolly Is sulticieut.i 21.REMARKS
36.105223 \ -77.925324 W water zones from 295ft to 315ft
6. !s(arc)the well(s): Permanent
22. Certification:
Is this a repair•to an existing well: No 1/20/2021
W/our 4wm,I urll CuuHrurIlnn rnG,ru„nnm,rgJ thr suture n/llir Sirnature of C rrtilied Well loony Ool Date ..
,runJrr _'!rruunk�,rrn,m u on lh< hurl,„l IhI,III I'll l.
Ih ,,I,nlrn�Jul Rnvr.l hr,Chi rrl'n1i Ih<II da-rrd(!Ic/u:r.,(it erc)cnadrueled in,r,uucfnnu
It all Ll;`+(.9r 0"C Al/uq ur 15.1:A'i'.1, o2( .02oo ll l-11 r'un+/ru,vlun.Sland,.n do and drnf u
�. �tl0l bel'Ot'Nel1s l'UOSt YII I'tfd: 1 rn;+1 r�/lluc ncon!h,l,,hocn lu•mv,(c',llu l/u'trcl/r!,rucl'.
oll/Illph,Int"lion ut'nun-try?hr rr,-IL�t!a/,) ;,alil III,'cunl,'ionNr(It V/an.),w cull 23. Site diagrani of additional-well details
,,,h,,m our/urn/ (A You may use the back of this page to provide additional well site details or well
`L%�' construction details. You mad also attach additional pages if necessarN.
t. I oral,sell depth below land surface: 420 p,+ GjaC) (ft.)
:,r o uh/rig u,Ih G,l,d/do/nln d,hgClrnl,,,umhle--+"a:_nn'aml I)') SI AIII T.11. !NSTRVCTIONS
Ifi,Static water Ie+ml below Cop of'casing: 15 (ft.) 24a.For All 11�eils_ `;tjbiwt thir,form within 30 daNs utcomplctiun of+sail
eonstruc11011 to the t",lic_ncing
ll,rr l�r<'!I,,.rhurc rcr+u tr,r
Divisimt ot`Nau•r ilurditx,Information Procession l'nit,
11. Borehole diameter: 6 (in.) 1617 flail Service Center.Raleigh,NC 27699-1617
12. N1rctl construction method: Rotary air tab. For h jection N ells: In adchion to sending the loam to the address to 24a
t e au;�r.ratan_,cable,direct push.ctc! above.also submit a cope of this rontt within 30 days of completion orwell
construction to the tollowina:
1.014 M A-1'FR St PPLA WELLS ONL1 Division ot'NN'ater QualitN.I ndergroun Injection Control Program.
1636 Haft Service(:enter,Raleigh,NC 27699-1636
13o, field(gpm): 4 Method of test: Air 24c_Forr\Nater Supoly lniection Wells: In addtion to sending the farm to
the address(c,,)above.also submit one copy of this limn within 30 days of
i 3I;. Disinfection tappet HTH lliount: 17 OZ complown of+Nell construction to the coonty health department of the county
v+herc con,tructc(.
.nni(i+b-I North Can ium llepartmenl of llmirunmw;d and Natural I�v,omces - I)i,i,,i n,.,f �1'arer()uality RCviscd 2!22,'16