GW1-2021-03649_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.
Well Contractor Name ft ft
3573-A S.O°TER CA ING(for mu_Iti- ase we Is OR Rif applica le
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
Lake Valley Well Co., Inc 0 ft 40 ft 6.25 in- SDR21 PVC plastic
Company Name ft. ft in.
16. . R CASING O B G gent erma closed o0
2.Well Construction Permit#: 328991 FROM TO DIAMETER TMCKNESI., MATERIAL
List all applicable well construction pertmits(te County,State, variance,etc. ft ft. in.
3.Well Use: ft ft in.
z scRE
FROM TO CKNESS SLOT S MATERIAL
Residential �� ft ft
ft ft
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
�V q
C�4`q� 0 ft ft
�C o
�;' 2 ft 40 ft
ft ft
(if(applicable)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft ft
4. Date Well(s)Completed: 4/14/2021 Well ID#
ft ft
5a. Well Location:
7404
G OG a c itio al s eels if necessary
List all applicable well construction pertmits ft County,State, Variance,etc. TO DESCRIPTION(color,hardness,soillrock type,grain size,etc)
Clayton Homes of Rocky Mount 024588 10 ft Cream Clay
Facility/Owner Name Facility ID(if applicable) 25 ft Tan Rock
Deerhaven CT Louisburg 27549 Lot 35 Louisburg Farm 35 ft Brown Rock
Physical Address,City,and zip 55 ft Red Rock
Franklin 2826-11-9242 ft Gray Rock
County Parcel Identification No.(PIN) ft ft
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft
(If well field,one lat/long is sufficient.)
36.113858 N -78.248615 W Water zones 185ft and 370ft
6. Is(are)the well(s): Permanent _
22. Certification:
7. Is this a repair to an existing well: No 4/14/2021
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 1 SA NCAC 02C.0100 or 1 SA 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: 404 (ft)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMTI'TAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 22 (ft)
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 I Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Iniection 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): 3 Method of test: Air 24c.For Water Supply Infection`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: 14 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