GW1-2021-03642_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
Hill 111
1.Well Contractor Information: 4• A ,ER ZQ. S
FROM TO DESCRIPTION
Sammy Rackley It. ft.
Well Contractor Name ft. ft.
i
3573-A cas f 5.OUTER CsAS G(for multi e ells)U R if applicable
NC Well Contractor Certification Number FROM TO m DIAMETER THICKNES MATERIAL
Lake Valley Well Co.,Inc 0 ft 81 It- 6.25 in. SDR21 PVC plastic
Company Name ft It. in.
6. R CASIN O UBING(geotherma closed oop
2.Well Construction Permit#: 36951 FROM TO DIAMETER TfUCKNESl MATERIAL
List all applicable well construction permits lie County,State, Variance,etc. ft ft in.
3.Well Use: ft. ft in.
7.SC
FROM TO DIAMETER TMCKNES SLOTS MATERIAL
Residential ft ft. in.
ft. ft. in.7
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft 2 ft rough
R�1.� �\nC� ft ft
j cc'�p� ft. ft.
P�` `���oc;' 9.S lGRA EL AC if applicable
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
,J ft. ft
4. Date Well(s)Completed: 5/14/2021 Well ID4�
III ft
5a. Well Location: (attach d itional IRS"!ts if n eUPry
List all applicable well construction pertmits(le County,State, Variance,etc. FROM «�TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
J E C Construction 0 ft 35 ft Orange Clay
Facility/Owner Name Facility ID(if applicable) 35 ft 50 ft Cream Sandy Clay&Sand
622 Pine Ridge RD Zebulon 27597 Lot 4 50 ft 125 ft Red Sandstone
Physical Address,City,and Zip 125 ft 202 ft Red Rock
Franklin 2728-27-4306 ft ft
County Parcel Identification No.(PIN) ft ft
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft
(If well field,one Iat/long is sufficient.) 1"
35.911567 N -78.248871 W Water zones at 125ft and 190ft
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No
t 5/14/2021
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
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: 202 (ft.)
For multiple wells list all depths ifdierent(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: 15 (ft)
water level is above casing,use If "+" construction to the following:
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 Injection 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): 10 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: 14 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