GW1-2021-04012_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
AN
1.Well Contractor Information: 14:WATTER`ZO.ES , 14
FROM TO DESCRIPT'lON
Sammy Rackley ft ft
Well Contractor Name fL ft
3573-A 5.O TIER CAS: G(form I.-case well OR ERM applicatil
NC Well Contractor Certification Number IFROM TO DIAMETERL THICKNES MATERIAL
Lake Valley Well Co., Inc 0 fL 51 ft 6.25 in. SDR21 PVC plastic
Company Name fL ft in.
16. RCS O 11" WG----'Irgeot canal Cos loop
2.Well Construction Permit#: FROM TO DIAMETER THICKNES4 MATERIAL
List all applicable well construction pertmits(te County,State, Variance,etc. ft fL in.
3.Well Use: fL fL in.
7.SC E
FROM TO DIAMETER THICKNES1 SLOT SIZ MATERIAL
Residential ft ft in.
ft ft in.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft 2 fL Conrrete I muting rough
fL 5,1 M Bpntnnbte 5
ft fL
RAPE C (ifapplicable
._ .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft M
ft. M
4. Date Well(s)Completed: 4/13/2021 Well ID#
fL ft
5a. Well Location: 20. G OG attach addi 'onal a eels if ecessary)
List all applicable well construction pertmits(ie County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Donny Lassiter 0 ft 10 ft Orange Clay
Facility/Owner Name Facility ID(if applicable) 10 fL 28 ft Cream Clay
133 Blue Heron DR Hendco 27842 Lot River Run Mill Stone 28 fL 45 ft Tan Rock
Physical Address,City,and Zip 45 ft 85 ft Tan Hard Rock x�
Northampton 85 ft 503 ft Gray Rock
County Parcel Identification No.(PIN) ft ft r3
Sb. Latitude and Longitude degrees/minutes/seconds or decimal degrees:
ft ft
(If well field,one lat/long is sufficient.) 21. MA S a
35.17895 N -77.87484 W Water zone at 195ft
6. Is(are)the well(s): Permanent
22. Certification: ^� �-�,,�•
7. Is this a repair to an existing well: No 4/13/2021
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Well Contractor Date
repair under#21 remarks section or on the back of this form. By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 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 to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 503 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100) SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 25 (ft) construction to the following:
If water level is above casing,use"+" Division of Water,Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Infection Wells: In addtion to sending the form to the address in 24a
(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): 1 Method of test: Air 24c.For Water Supply Infection Wells: In addtion to sending the form to
the address(es)above,also submit one copy of this form within 30 days of
13b. Disinfection type: HTH Amount•_ 16 OZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16