GW1-2021-04122_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
i
This form can be used for single or mutiple wells
4. Aff R
1.Well Contractor Information:
FROM TO DESCRIPTION
Sammy Rackley ft ft
Well Contractor Name ft ft
3573-A a .O TIER GAS G fo 1'-e a Is O R(ifs plica le
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
Lake Valley Well Co.,Inc 0 ft 61 ft 6.25 in. SDR21 PVC plastic
Company Name ft ft in.
6. R C*AS O ge ermalFos
2.Well Construction Permit#: GW-052616-2021 FROM TO DIAMETER TMCKNES MATERIAL
List all applicable well construction pertmits lie County,State,Variance,etc. ft ft in.
3.Well Use: ft ft in.
7. G
FROM TO DIAMETER TMCKNES4 SLOT S MATERIAL
Residential ft ft in.
ft ft in.
,,.,, a✓;v FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. 2 ft
Concrete I Grouting Through
2 ft60 ft
�r -;��:•'� ft ft
d pp ica le
-'�'u.ram_•`' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
d ft ft
�•4. Date Well(s)Completed: 7/9/2021 Well tD# ft ft
ft ft
5a. Well Location: 20. G G a ac a i Must 'f ecessary
List all applicable well construction pertmits lie County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
RHC Construction 0 ft 25 ft Cream Clay
Facility/Owner Name Facility ID(if applicable) 25 ft 30 ft Brown Sandstone
3008 New Watkins Ln Raleigh 27616 Lot 15 Watkins Place 30 ft 35 ft Brown Rock
Physical Address,City,and Zip 35 ft 60 ft Gray Rock
Wake 1746687936 60 ft 383 ft Gray Granite
County Parcel Identification No.(PN ft ft
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft
(If well field,one lat/long is sufficient.) 2 M.
35.5142 N -78.3019 W Water zones at 350ft and 37,5ft
6. Is(are)the well(s): Permanent
22. Certification: ;' cr At,"
7. Is this a repair to an existing well: No 41 7/9/2021
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 1 SA 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: 383 (ft.)
For multiple wells list all depths ifdifferent(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 45 (ft)
construction to the following: j
Ifwater 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): 25 Method of test: Air 24c.For Water Supply Iniectio1n 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