GW1-2021-03637_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: FROM TO DESCRIPTION
Sammy Rackley ft. ft
Well Contractor Name ft It.
I
3573-A 5.O ER OA for u ti- a e ells O R(if a icable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
Lake Valley Well Co., Inc 0 ft 75 ft 4 in- SCH40 PVC plastic
Company Name ft ft in.
b. RCAS G G geo ermalc ose ,loop,
2.Well Construction Permit#: 202195-W FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits(ie County,State, Variance,etc. ft ft in.
3.Well Use: ft ft in.
.E.
FROM TO DIAMETER THICKNES SLOT S14 MATERIAL
Residential 75 ft 105 ft 4 in. PVC plastic
ft ft. in.
18.GRO:
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft 2 ft
Conrete I Grouting Through
ft 65 ft
ft ft
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
65 ft 105 ft 2 Filter Sand 25 Grouting Through
ft ft
4. Date Well(s)Completed: 5/28/2021 Well ID#
ft ft
5a. Well Location:
20. L G G a ch ditional . eets�f ecessary
List all applicable well construction pertmits(te County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Sylvia Brown 0 ft 3 ft Black Topsoil
Facility/Owner Name Facility ID(if applicable) 3 ft 10 ft Gray Clay
131 Gatewood LN Tarboro 27886 Lot 10 ft 25 ft White Sand&Gravel �,`�
Physical Address,City,and Zip 25 ft 40 ft Gray Clay&Sand 0
Edgecombe 01-4747-58-7906 40 ft 45 ft Gray Clay A
County Parcel Identification No.(PIN) 45 ft 65 ft Red Clay: �\^• r�C'' (�
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 65 ft. 75 ft Gray Clay
(If well field,one tat/long is sufficient.) 21•
35.881552 N -77.495204 W
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 5/28/2021
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,I 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
8. 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: 105 (ft)
For multiple wells list all depths if dierent(example-3@ 200'and 2 @ 1009 SUMTTTAL 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: 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
(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): 55 Method of test: Air 24c.For Water Supply Iniection<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: 12 OZ completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16
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