GW1-2022-08361_Well Construction - GW1_20220907

WELL CONSTRUCTION RECORD For Internal us"
This form can be used for single or mudple wells f
14aWATBR'
1.Well Contractor Information: ZONES
-
FROM I TO DESCRIPTION
Sammy Racktey I
Well Contractor Name tt ftft ft. f
3573-A IS:.OUTER'GA51NG(for multi-sased.wetls)OR LINER'(if•applicable)
NC Well Contractor Certification Number FROM TO DIAMETER 7MCKNES MATERIAL.
Lake Valley Well Co.,Inc 0 ft 202 ft. 4 f I'L SCH40 PVC plastic
Company Name & ft. I in.
I6 SINNER CASING OR TUBING.(geothermai ciosed'Ice
2.Neil Construction Permit N: PW52022-100687 FROM TO D[Al\fETER MCKNFS MATERIAL
Lin all applicable well construction penmas 0e County,Stale.Vanana,eta ft, fl. in
3.Well Use: ft. ft. in
17:,SGREEN FROM TO DIMtETER THICKNES4 SLOTS MATERIAL
Residential fff ft. 222 ft. 4 in. PVC plastic
ft ft.
18:tGROIi'1'
FROM---TO--MATERIAL ----EMPLACEMENT-METHOD&AMOUNT
it ft.
ft ft.
M ft
19.5AA--— RAVEL PACK(&.pplicatile)'
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
186 ft 222 ft. 02 Filter Sand 20 Grouting Through
4. Date Well(s)Completed: 8/17/2022 Well IDN It. ft
ft ft
Sa. Well Location: 20:DRILLINGMQG(attach additional sheets it necessary)
List all applicable Nell construction penmiis#e Cointly,State,Variance,eta FROM TO DESCRIPTiON(color,hardness,soiVrock e in, sizo etc
Tyler Williams Builders - - 0[t 2 ft. Black Topsoil ar.'Fawlity/Owner Name Facility ID(ifopplicable) 2 ft 18 ft. White Sandy Sand ^~ INIP"
5326 NC 43 N Greenville 27043 Lot 7 18 ft 55 ft. Black Hard Clay
PWcal Address,City,and tip 55 ft 67 ft. Red Hard Clay
Pitt 78382 67 ft 80 ft. Black Fine'Sand Pr,-L,,�ZGWg Unil,
Courq Parcel Identification No.(PIN) 80 ft 95 ft. Red Hard Clay L". CUSOG
Sb. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 95 fL 100 It. White Fine ISand
(If well field,one lot/long is su6cienL) 21aREM1tARKS `
35.68222 N -77.465885 W I!E
6. Is(are)the well(s): Permanent 22. Certification:
Sc+xxy mac.A
7. Is this a repair to an existing well: No U 8/1712022
If this is a repair,Jill out brown well comtruction Inormatlon and explain die nature of the Signaturo of Certified Well Contractor Date
repair under 921remarks section or on the back of this fart. Byslgning this form,I hereby crrdify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Corutntction Standards and that a
S. Number of wells constructed: 1 copy of ills record has been provided to the well owner.
For multiple injection or non-wnrer wells ONLY with the sane construction,you can 23. Site diagram or additional well details:
submit oncfoma 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: 222 (ft)
For multiple wells list all depthr(f diFerent(example-3@ 200'and 2 @ 1009 SUMITI'AI,INSTRUCTIONS
10.Static water level below top of casing: 50 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
1fNmerinYlis above casing,use'+• construction to the following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 10 (in.) 1617 Mail Sen'ice Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary-mud 24b.For Inieetion Welts: In addtion'io sending the form to the address in 24a
(Le.Zug-.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 HELLS ONLY: Division of Water Quality,U Idergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 75 Method of test: Air 24c.For Water Supply Inieetion Welts; 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 OW-1 North Carolina Dcpamucnt of Environment and Natural Resources -Division of Water'Quality Revised 2122/16
h