GW1-2021-03880_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information:
FROM TO DESCRIPTION
Sammy Rackley ft. ft f
Well Contractor Name ft. ft
f :
3573 A o u s ifIpicabe
NC Well Contractor Certification Number FROM TO DIAMETER TMCKNES MATERIAL
Lake Valley Well Co.,Inc 0 ft 105 ft 6.25 in 188 Steel-galvanized
Company Name ft ft in.
6. R AS O G eo ermal c ose oop
2.Well Construction Permit#: E21-000518 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits lie County,State,Variance,etc. ft ft in.
3.Well Use: ft ft in.
7. GRE:
FROM TO DIAMETER THICKNES SLOT S MATERIAL
Residential ft ft in.
ft fL in.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft Concrete I Grouting Through
ft ft
ft ft
78f
MIM O MATERIAL EMPLACEMENT METHOD&AMOUNT
ft
ft
4. Date Well(s)Completed: 6/23/2021 Well 1D# ft
5a. Well Location: OG a c a i'ona s eets•f ogre aList all applicable well construction pertmits lie County,State,Variance,etc. O DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Joel Boseman Boseman Farms 017204 8 ft Cream Clay
Facility/Owner Name Facility ID(if applicable) 5 ft Cream Sandy Clay&Sand
1000 Cummings RD Battleboro 27804 Lot 5 ft Gray Clay
Physical Address,City,and Zip 5 ft Brown Clayey Shale ,r.� •; �'
Nash 385206387863 85ft 1100 ft Gray Shale ,
County Parcel Identification No.(PIN) 100 ft 303 % Gray Rock
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft J
(If well field,one lat/long is sufficient.) 2
36.021593 N -77.808364 W Water zone at 290ft
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No
6/23/2021
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 I5A 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: 303 (ft)
For multiple wells list all depths if dierent(example-3@ 100'and 2 @ 100 J 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 (17)
construction to the following:
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
24b.For Infection Wells: In addtion to sending the form to the address in 24a
12. Well construction method: Rotary air
(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): 35 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
15 OZ completion of well construction to
13b. Disinfection type: HTH Amount: the county health department of the county
where constructed. I f
Water
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Quality Revised 2/22/16
1