GW1-2021-03866_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
Y4.WA�TiFrR 7ANES
1.Well Contractor Information:
FROM TO DESCRIPTION
Sammy Rackley ft. ft.
Well Contractor Name ft ft
3573-A 5.O ER C. ING for m I_ti- ase welts O R(if ap'licable
NC Well Contractor Certification Number FROM TO DIAMETER TfflCKNESl MATERIAL
Lake Valley Well Co.,Inc 0 ft 64 ft 6.25 in- .188 Steel-galvanized
Company Name ft ft. in.
B G(geotherma close loop
2.Well Construction Permit#: E21-000505 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.
7 3C E
FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential ft ft
ft ft.
8.GRO+T
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft 2 ftconcrete 1 Grouting Throt gh
ft 60 ft
ft ft
(ifapplica le
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft.
ft ft
4. Date Well(s)Completed: 4/20/2021 Well tD#
ft ft
Sa. Well Location: 20. ING 11
OG(a c_addition 1 s eets'f necessary
List all applicable well construction perimus lie County,State, Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Tyler Dickson 336319 0 ft 35 ft Orange Clay
Facility/Owner Name Facility ID(if applicable) 35 ft 55 ft Brown Shale '!
10507 Herman Lane Nashville 27856 Lot 55 ft 65 ft Gray Shale �<
Physical Address,City,and Zip 65 ft 215 ft Gray Rock tg ,`.,•»°`
Nash 381600623359 ft ft 2
County Parcel Identification No.(PEN) ft ft
t
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft ; ,�t`
(If well field,one lat/long is sufficient.) 1.-..
36.112946 N -77.928394 W Water zones at 122ft and 170ft
6. Is(are)the well(s): Permanent
22. Certification: xr%.�4
7. Is this a repair to an existing well: NO
4/20/2021
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 farm,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 ONLYwith 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: 215 (ft.)
For multiple wells list all depths ifdgerent(example-3@ 200'and 1 @ 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:
Ijwater 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:
i
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality;Undergroun Injection Control Program,
1636 Mail Service lCenter,Raleigh,NC 27699-1636
13a. Yield(gpm): 15 Method of test: Air 24c.For Water Supply Iniection Wells: In addtion to sending the form to
the address(es)above,also submitione 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. E
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16