GW1-2021-06707_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: WATER ZONE
FROM TO DESCRIPTION
Sammy Rackley
Well Contractor Name
3573-A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
Lake Valley Well Co., Inc 0 ft. 76 ft- 6.25 in- .188 Steel-galvanized
Company Name ft. ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: E21-000183 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.
17.SC
FROM TO DIAMETER THICKNESSS SLOT SIZE MATERIAL
Residential ft. ft. in.
ft. ft. in.
18.GR T AN
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. 2 ft. Concrete I Grouting Through
2 ft. 7ff ft.
ft. ft.
19.SAND/GRAVEL PACK(if applicable
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft.
ft. ft.
4. Date Well(s)Completed: 10/19/2021 Well ID#
ft. ft.
5a. Well Location: 7U7.DRIOLIN L ttach additional sheets if necessary)
List all applicable well construction pertmits(ie County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Poland Builders 335865 0 ft. 2 ft. Brown Sandy Topsoil
Facility/Owner Name Facility ID(if applicable) 2 ft. 22 ft. Orange Clay
4979 Joe Ellen RD, Battleboro,27809 Lot 7 22 ft. 30 ft. Orange Sand
Physical Address,City,and Zip 30 ft. 60 ft. Orange Sandy Clay
Nash 38330051311 60 ft. 70 ft. Black Clayey Shale
County Parcel Identification No.(PIN) 70 ft. 183 ft. Gray Rock
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft.
(If well field,one lat/long is sufficient.) 21.REMARKS
36.028954 N -77.864966 W Water zones at 107ft, 115ft, 132ft to 135ft and 160ft
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No a_ 10/19/2021
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 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: 183
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 15 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
If 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 Injection 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): 15 Method of test: Air 24c.For Water Supply Injection 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: 12 OZ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16
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DRILLING LOG(attach additional sheets if necessary) ATER ZONES
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc) FROM TO DESCRIPTION
0 2 Brown Sandy Topsoil
2 22 Orange Clay
22 30 Orange Sand
30 60 Orange Sandy Clay
60 70 Black Clayey Shale
70 183 Gray Rock
OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
0 76 6.25 .188 Steel-galvanized
INNER CASING OR TUBING(geothermal closed loop)
FROM TO DIAMETER THICKNESS MATERIAL
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 2 Concrete 1 Grouting Through
2 70 Bentonite slurry 15 Tremie Pipe
AND/GRAVEL PA
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
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