GW1-2021-03859_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
�I4.W ER ZONES ��
1.Well Contractor Information: FROM TO DESCRIPTION
Sammy Rackley ft ft
Well Contractor Name ft ft
3573-A 5.O R CrAS .G f_or ulti-case wells R if ap lie le
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
Lake Valley Well Co.,Inc 0 ft 37 ft 6.25 in. .188 Steel-galvanized
Company Name ft ft in.
6. R AS G B (geoth rma closed loop
2.Well Construction Permit#: E20-001039 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction permuts(te County,State, Variance,etc. ft ft in.
3.Well Use: ft ft in.
7. G
FROM TO DIAMETER I THICKNES1 SLOTSI# MATERIAL
Residential ft. M in.
ft ft in.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. 4 ft rnnrrete 3 Grouting-Thmugh
ft36 ft Flentoites mit.Pipe
ft ft
9.S /GRA C (if applicab e
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft ft
4. Date Well(s)Completed: 3/4/2021 Well ID#
ft ft
5a. Well Location: 0. G O attac ad itionalsheets if ecess ry.
List all applicable well construction pertmits ft County,State, Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Michael Langley 335364 0 ft 15 ft Orange Clay
Facility/Owner Name Facility ID(if applicable) 15 ft 30 ft Cream Sandy Clay
5321 Ryland LN Rocky Mount 27803 Lot 30 ft 302 ft Gray Rock
Physical Address,City,and Zip ft ft
Nash 373700207078 ft It.
County Parcel Identification No.(PIN) ft ft
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees:
ftz`
ffiis' Will �.r:fJ1
(If well field,one lat/long is sufficient.) 21. S
NNOMAIMONNOMMM
35.848467 N -77.876222 W Water zones between 275ft to 278ft,at 275ft and 285ft
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 3/4/2021
1f 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 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,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: 302 (M)
For multiple wells list all depths if d fferent(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: 75 (ft)
construction to the following:
1f 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 Iniection Wells: In addition 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): 40 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