GW1-2021-04137_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14 WATER ZONES
1.Well Contractor Information: -.
IFROM TO DESCRIPTION
Sammy Rackley --
-• �-
Well Contractor Name
ft 1 ft.
3573-A 15 OUTEWCASING((or multi used welts)OR LINER(tfapphcable)
NC Well Contractor Certification Number !FROM TO DIAMETER THICKNESS MATERIAL
Lake Valley Well Co., Inc 0 ft 115 ft. : 4 in. SCH40 i PVC plastic
Company Name ---- - - ft. ft. ; in.•
16,INNER CASING"OR TUBING(geothermal closed loop)" ��"�°'
2.Well Construction Permit#: FR_OM THICKNESS TO DIAMETER THICKN MATERIAL
List all applicable well construction pertmits(ie C'ounty,State, Variance,etc. ft. I ft.7 -
3.Well Use: ft _ ft L in.
1 �7 SCREEPr ...
`� j FROM TO r DIAMETER I THICKNESS SLOT SIZE MATERIAL
115 ft.p
Residential in.i 4 . PVC plastic„o
ft L_ r� to
i$"GROUT
'. 9,J
FROM TO MATERIAL - _EMPLACEMENT METHOD&AMOUNT
ft. 1 ft.-!—Concrete---.----:------1 Groutin -Through---- --.
ft.IT-111)f�-Bentonite_s)uri Tr_emis_Pipe__-__._-
r ft
s\ � ft
\i '' 0 19 SAND/GRAVEL PACK{tt applicable) ,^'�-^ _. _u� `__ y
FROM
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
1110 ft. 1 135 ft.#2 Filter Sand 16 Grouting Through
4. Date Well(s)Completed: 2/8/2021 Well ID# ft. ft.
Sa. Well Location: 20 ARILLING 7'OG(attach additonal sheets rf oeces5a �'
List all applicable well construction pernnns(ie County.State, Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Brandon and Joe Webb -- -- ----- — ---- - - -----
- -- - -- ---- --- ... -- ---- --- -Name Facility
Oft. 12 ft. Orange Clay
- - -- -- - - -- -
Facility/Owner Nae Facility ID(if applicable) --
12 ft 15 ft. White Gravel
-- -- -- - -
6529 Good News Church Road Stanttonsburg Lot -----
_ — 15 ft j 20 ft.I Cream Clay
Physical Address,City,and Zip 20 ft 40 ft. White Sand
Wilson 40 ft. 55 ft. Blue Clay
County Parcel Identification No.(PIN) L 55 ft. j 75 ft. Gray Clay
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 75 ft. 1 85 ft l White Sand
(If well field,one latAong is sufficient.) 21 REMARKS
35.689438 N -77.761919 W rI ---- -- --- --- -- - -- - - --- - -
6. Is(are)the well(s): Permanent
---- 22. Certification: a
7. Is this a repair to an existing well: No 2/8/2021
1f this is a repair,,frll out brown well construction in/brination and explain the nature o/'the Signature of Certified Well Contractor Date
repair under','2/remarks section or on the hack gfMis/orm.
By signing Ihis.lornv,/hereby c•erli/y tl?at the wells)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,volt 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: 135 (ft.)
For multiple wells list all depths/fdtjfbrent(example-3a 200'and2 cCi 100J SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 65 (tt) 24a.For All Wells: Submit this form within 30 days of completion of well
If water level is above casing,use"{" — construction to the following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 10 ---on.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary-mud 24b.For Iniection 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 Service4Center,Raleigh,NC 27699-1636
13a. Yield(gpm): ---50 - - Method of test: Air 24c.For Water Supply Iniection Wells: In addtion to sending the form to
- the address(es)above,also submif 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.
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16
I .