GW1-2022-04975_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 14.WATER ZONE
FROM TO DESCRIPTION
Sammy Rackley
ft. ft.
Well Contractor Name ft. ft.
3573-A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
Lake Valley Well Co., Inc 0 ft. 27 fl• 4 in. SCH40 PVC plastic
Company Name ft. ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: 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.SCREEN
FROM TO DIAMETER THICKNES SLOT SIZ MATERIAL
Residential 27 ft. 67 ft. 4 in. PVC plastic
ft. ft. in.
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 2 ft. Concrete I Grouting Through
2 ft. 25 ft.
ft. ft.
19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
25 ft. 67 ft.#2 Filter Sand 29 Grouting Through
ft. ft.
4. Date Well(s)Completed: 5/17/2022 Well ID# ft. ft.
5a. Well Location: IrtMING L (attar 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)
Sylvan Heights Bird Park 0 ft. 2 ft. Black Topsoil
Facility/Owner Name Facility ID(if applicable) 2 ft. 15 ft. Orange Sand&Clay
500 Sylvan Heights Park Way, Scotland Neck,27874 Lot 15 ft. 22 ft. Orange Clay
Physical Address,City,and Zip 22 ft. 35 ft. White Coarse Gravel
Halifax 35 ft. 67 ft. Gray Sandy Shells
County Parcel Identification No.(PIN) 62 ft. ft.
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft.
(If well field,one lat/long is sufficient.) 1.REMARKS
36.0846 N -77.2453 W
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No � 5/17/2022
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: 67
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100) SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 19 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Ifwarer level is above casing,use"+" Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 9 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary-mud 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): 20 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-1 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 neces
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc) FROM TO DESCRIPTION
0 2 Black Topsoil
2 15 Orange Sand&Clay
15 22 Orange Clay
22 35 White Coarse Gravel
35 67 Gray Sandy Shells
62
OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
0 27 4 SCH40 PVC plastic
(INNER CASING OR TUBING(geothermal closed loop)
FROM TO DIAMETER THICKNESS MATERIAL
SCREE
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
27 67 4 PVC plastic
GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 2 Concrete 1 Grouting Through
2 25 Bentonite slurry 2 Tremie Pipe
SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
25 67 #2 Filter Sand 29 Grouting Through
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