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HomeMy WebLinkAboutGW1-2023-00028_Well Construction - GW1_20230103 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. 113 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 Agricultural 113 ft. 133 ft. 4 in. PVC plastic ft. ft. in. 18.GROUT FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT 0 ft. 65 ft. ft. ft. ft. ft. 19.SAND/GRAVEL PACK(if applicable) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ft. ft. ft. ft. 4. Date Well(s)Completed: 12/9/2022 Well ID# 5a. Well Location: ING L13G(attach 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) Bennett Bradley 0 ft. 1 ft. Brown Topsoil Facility/Owner Name Facility ID(if applicable) 1 ft. 12 ft. Orange Clay Rest-A-Bit Road, Tarboro,27886 Lot 12 ft. 20 ft. White Sand&Clay Physical Address,City,and Zip 20 ft. 35 ft. Blue CLAY&SHELL Edgecombe 35 ft. 40 ft. White Sand County Parcel Identification No.(PIN) 40 ft. 55 ft. Red Clay 5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 55 ft. 75 ft. Gray Clay (If well field,one lat/long is sufficient.) 1.REMARKS 35.806779 N -77.55892 W 6. Is(are)the well(s): Permanent 22. Certification: 7. Is this a repair to an existing well: No � 12/9/2022 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: 133 For multiple wells list all depths if different(example-3@ 200'and 2 @ 100) SUMITTAL INSTRUCTIONS 10.Static water level below top of casing: 30 (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): 80 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 Page 1 DRILLING LOG(attach additional sheets if neces FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc) FROM TO DESCRIPTION 0 1 Brown Topsoil 1 12 Orange Clay 12 20 White Sand&Clay 20 35 Blue CLAY&SHELL 35 40 White Sand 40 55 Red Clay 55 75 Gray Clay 75 83 Red Clay 83 90 White Fine To Coarse Sand OUTER CASING(for multi-cased wells)OR LINER(if applicable) 90 95 Gray Clay FROM TO DIAMETER THICKNESS MATERIAL 95 133 White Fine To Coarse Sand 0 113 4 SCH40 PVC plastic (INNER CASING OR TUBING(geothermal closed loop) FROM TO DIAMETER THICKNESS MATERIAL SCREE FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL 113 133 4 PVC plastic GROUT FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT 0 65 Bentonite slurry 6 Tremie Pipe SAND/GRAVEL PACK(if applicable) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN Page 2