GW1-2021-03856_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: mm
4.W TAR ZONES
FROM TO DESCRIPTION
Sammy Rackley ft. ft.
Weil Contractor Name ft ft.
3573-A S G for multi-cased ells OR R if a plicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
Lake Valley Well Co.,Inc 0 ft 81 fl- 6.25 in. .188 Steel-galvanized
Company Name ft. M in.
6. RCS OR BING(geo herma closed loop
2.Well Construction Permit#: E20-001553 FROM TO DIAMETER THICKNES§ MATERIAL
List all applicable well construction pertmits(te County,State,Variance,etc. ft ft, in.
3.Well Use: ft ft in.
7,SCsR E
FROM TO DIAMETER THICKNES SLOT S MATERIAL
Residential ft M in.
ft ft. in.
gam
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
ft 2 ft mybIIgThrough
ft ftllur)tie Pipe
ft ft
9. /G L C ifappli able
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft. ft
4. Date Well(s)Completed: 3/9/2021 Well ID#
ft. ft.
5a. Well Location: 20. G OG attach itiona eets if necessary
List all applicable well construction pertmits(te County,State, Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
J E C Construction 335323 0 ft 8 ft. Orange Clay
Facility/Owner Name Facility ID(if applicable) 8 ft 12 ft. Brown Boulders
8167 US 264A Bailey 27807 Lot 15 12 ft 28 ft. Orange Clay&Cobble .
Physical Address,City,and Zip 28 ft 45 ft Orange Clay
Nash 275300296385 45 ft 75 ft Brown Shale u(2
County Parcel Identification No.(PIN) 75 ft 142 ft Gray Rock
Sb. Latitude and Longitude degrees/minutes/seconds or decimal degrees:
(If well field,one latllong is sufficient.) -
35.779332 N -78.148344 W Water zones at 110ft, 115ft and 125ft
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 3/9/2021
lfthis 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: 142 (ft)
For multiple wells list all depths if dierent(example-3@ 200'and 2 @ 100) SUMITTAL 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 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): 30 Method of test: Air 24c.For Water Supply Iniectio'n 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
1