GW1--03161_Well Construction - GW1_20230505

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or inutiple welts 4
i..IVVATERIONES
1.Well Contractor Information: 1TROlt1 TO DESCRIPTION
Sammy Rackley j
ft. ft
Well Contractor Name
ft. tt.
3573-A I15.OUTER CASING(for multi=cased.ivells)OR LINER(if a)iphcable)
NC Well Contractor Certification Number (FROM TO DIAMETER THICKNESS MATERIAL
Lake Valley Well Co.,Inc p It' 76 ft 6.25 '" _ SDR21 PVC plastic
Company Name l ft. ft. in.
2.Well Construction Permit#: 370704 16.iNNERCASI1\G,OR TUBING(geothermal closed loop) -.
FROM TO DIAMETER THICKNESS MATERIAL
list aU applicable well construction pert+nits rie Cotoay.State,birrimrce.etc —_ ft. ft. in.
3.Well Use: ft. ft. in.
!FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential (I ft. fr. in.
I ft. ft. in.
t18.GROUT
FROM TO_ MATERIAL--M CEMLNI ME1'HOL) AMOUNT
..2. ft- TO,ft._ Bentonite sttsiy-- T... - Tremie Pipe_...
—1--- --
119.SAND/GRAVELT PACK(tf applicable),
r �
FROM TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
i ft. ft.
ft. ft.
4. Date Well(s)Completed: 6/23/2022 WcI1.ID# I '
ft. ft.
5a. Well Location: M.DRLLLING:LOG'(attact►adcttfloaalsheets tf necessary]:
List all applicable irell construction per•anits tie Cavort,.Stare.I-ariwtce.etc, FROM TO DESCRIPTION(color,hardness,soil/rock type,!,,rain size,etc)
Cassidy Sykes - -- ---- -------- -- ------ -._... —-- -- ----
0 ft. 22 ft. Orange Clay
Facility/O"mrNanx raethtv10fifapphcable) 22 ft. 40 ft, Brown Clay
1040 Lettuce Hal)Rd Louisburg 27549 Lot t t +
sical Address,City,and Yip 70 ft. 90 ft. Red Sandstone
PhN 40 ft. 70 ft. Brown San
_ - _ _ tone
Franklin 2843-33-1243 90ft. 182 ft Red Rock �fA,r 5 2023
Cotmw ParretidCRnfKattontti0 tfNNI it. ft.
5•ad;r'tA,e�1,,�,�
ib. Latitude and Longitude degrees/minutes/seconds or decimal degrees:
t If well field,one lat/tottg is sutticient I 21 REMARKS'. -
36.036917 N -78.177412 11' Water zones at 90ft 105ft and 170ft
6. is(are)the well(s): Permanent 22. Certification: f�l.Stti -1 i-Cl:
7. Is this a repair to an existing well: No 6/23/2022
If this is it repair.fill out knouu well construction information and e-splaut the nano•e of the Signature of Certified Well Contractor Date
repair wider a 21 remarks section or or the.hack of this form. BY signing this form.i hereby certify that the vell(s)eras(here)constructed in accordance
utth 15.4 XCIC•02C.0100 or 15.4 NC IC 02C.0200 Well Const uciion Standards and that a
S. Number of wells constructed: 1 calm•ofthis record has been provided to the yell muter.
For mahtple h jection or non-water trells ONV'u"tth rite sanie construction,volt can 23. Site diagram or additional well details:
submit orteforni. 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: 182 (fLl
For multiple it ells list all depths ifrii(jerent!example-310)200'and?c-.1007 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 15 (ft.) 24a.For All!fells: Submit this form within 30 days of completion of well
Ifirarer level is abore casitrb,are"-" construction to the following:
Division of Water Quality,Information Procession Knit,
11. Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24h.For infection Wells: In addtion to sending the form to the address in 24a
(i.e.auger,rotas},cable,direct pustn,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,
1 1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Vield'(gpm): 12 Method of test: Air 24c..For Water Supply lniection?felts: in addtion to sending the foot to
the address(es)above.also submit one copv 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 Carolttna Department of(environment and Natural Resources - Division of Water Quality Revised 222/16