GW1-2021-03663_Well Construction - GW1_20210823

For Internal Use ONLY: `-----------------------___.-__-_--.._-_ __
WELL CONSTRUCTION RECORD This form can be used for single or mutiple wells
1.Well Contractor Information:
FROM TO DESCRIP T
Sammy Rac
ION
Sakley ( _ � - - -
— my Ras
Well Contractor Name ft ft
71
3573-A 15 , V, ERIt"'WNC{for 3nul ased wells)OR Z INEIR(tf applicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
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Lake Valley Well Co.,Inc 0 ft 52 ft 4 in. SDR21 PVC plastic
I ----ft. � ft.
Company Name 1O
6 INL!tip TNG¢fit (7BINC(gebtlYermAl f A ti�op) --
2.Well Construction Permit#: 1908 - �
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perunits 6e County,State, Variance,etc.
-- --
3.Well Use: a ^ft. ft. j in
� ma.tb...,:•y. —...._.a....sNd.c1 _v._:�.� ,. _...�......u�s K.....- E_. - >. ? .. .._
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential 52 ft. 72 ft. 4 in. PVC plastic
ftn ft in.
FROM 1 TO L MATERIAL EMPLACEMENT METHOD&AMOUNTY_€.
—Concrete:--
- — — - ---
ft. ft. • 1—Grouting.Ihrough_______
77-77
1AIYDJGRA 1'E i�G1C 4tf aplrcable�
_- - I- ---
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
~ --- -- - -
— Sand ; 15 Grouting Through 47 ft. I 72 ft #2 Filter Sa - -
--- —
ft. ft
4. Date Well(5)Completed: 2/4/2021 Well ID#
ft ft
5a. Well Location: a
20 DRILL�NC�S 1,OG jattach additional sfieets tftnec�ssary) „ ,�b,
List all applicable well construction pertmits lie County,State, Variance,etc
FROM TO j DESCRIPTION(color,hardness,sod/rock type,},Ram size etc)
Marcy Ricks -- -- -- -- -- -
0 ft 35 ft Orange Clay
Facility/Owner Name Facility ID(if applicable) 35 ft 50 ft Gray Fine Sand&Clay QR,
3537 Hwy 258 Scotland Neck 27874 Lot - - -
50 ft 72 ft White Gravel&Sand �° t
Physical Address,City,and ZipVIV
Halifax 11-03310 ft ft
County Parcel Identification No (PIN) ft ft
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: i ftnit
(If well field,one lat/long is sufficient.) d -
36.162605 N -77.407844 W
6. Is(are)the well(s): Permanent -------- — --------------------------------
- -- ------ 22. Certification:
7. Is this a repair to an existing well: No 2/4/2021
1/'this is a repair,,fill out known we//construction in/onnation and explain the nature of the Signature of Certified Well Contractor Date
repair under-'21 remarks section or on the back ol'thi.c./ottn' g signing this brnt,1 hereby semi that the wells was were constructed in accordance
Y• 8 R 1 1 1Y U (were)
with 15A NC'AC.'02C.0100 or I5A NC'A('02C.0200 Well Construction.Standards and that a
S. Number of wells constructed: 1 copy of this record has been provided to the well owner.
For multiple injection or non-water wells ONLY with the same construction,you can 23. Site diagram or additional well details:
submit one form. You may use the back of this page ito provide additional well site details or well
construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 72 SUMITTAL INSTRUCTIONS
(ft.)
For multiple wells list all depths i/di/jeren[(exam a(example-3 200'and 2 @ l00)
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10.Static water level below top of casing 33 (ft. 24a.For All Wells: Submit this form within 30 days of completion of well
- ---- - -- - -- - ) construction to the following
If water level is above casing use" b'
Division of Water Qtiality,Information Procession Unit,
11. Borehole diameter: - 10 -_(in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary-mud 24b.For Infection Wells: In addtion to sending the form to the address in 24a
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(i.e.auger,rotary,cable,direct push,etc.) above,also submit a copy of this form within 30 days of completion of well
construction to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 50 Method of test: Air 24c.For Water Suuoly Iniection Wells: In addition to sending the form to
-- --- -- the address(es)above,also submit o'ne.copy of this form within 30 days of
13b. Disinfection type: HTH Amount: 12 OZ completion of well construction to the county health department of the county
- ---------- _---- _--.------------____-__---:.___--I where constructed.
Fonn GW-I North Carolina Department of Enviromnent and Natural Resources - Division of Water Quality Revised 2/22/16
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