GW1-2022-00130_Well Construction - GW1_20221219

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WELL CONSTRUCTION RECORD For Intemal Use ONLY:
Tbis form can be used for single or mutiple wells
Id:WATER.ZONES :''
1.\Vcll Contractor Information: FROM TO DESCRIPTION
Sammy Rackley ft. ft.
Well Contractor Name ft. ft.
3573-A 15:.0UTER CASING.(. mu1H'sasi d1vf911s):OR LINERt(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER MCKNESS MATERIAL
Lake Valley Well Co„Inc 0 ft. 156 ft- 4 in. SCH40 PVC plastic
Company Name ft. fL in.
I6:INN_ ER CASING:OR:T:I7DING:(geottiermal.closedloop)
2.Well Construction Permit 9: PWS2022-1000731 FROM TO DIAMETER THI MATERIAL
List all applicable well construction pertmits(le Coumy;State,Variance,etc. ft. ft. in.
3.Well Use: ft. ft. in.
17:•;SCREEN;+'�:;� :�"� �..,,.,`Y;;y�;.
FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential 156 ft. 176 ft. 4 in. PVC plastic
fit. fit. ia.
FROM—TO—_ —MATERIAL_——EMPLACEMENT.METHOD.&AMOUNT —
ft. ft. granulargpto 1 Groutino Through
il- 65 ft- Renknite-qltjr V 4 Tremle P ne
It. ft.
19..•SANDlGRA\rEL-PACK+(if•applicable)
FROM TO MATERIAL EMPLACEMEWr METHOD&AMOUNT
ft. ft.
ft. ft.
4. Date Well(s)Completed: 12/8/2022 Well IDII fit. fit.
5a. Well Location: 20.'DRI_L•LiNG1LOG`(tfttach a�dit'ioual sheets if•:neccssary)
List all applicable well construction pertmits(ie Courtly;Stale,Parlance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Cesar and Rose Colon 0 ft. 2 ft. Black Topsoil
Facility/OwnerName Facility ID(if applicable) 2 ft. 15 ft. Orange Clay `� °� ' i V 4_.,L11",
1040 NC 121 Greenviga 27834 Lot 15 ft. 22 ft. Orange Sand ,
Physical Address.City,and Zip 22 ft. 30 ft. White Fine Sand — Z L L_
Pitt 09764 30 ft. 60 ft. Gray Sandy Clay .?;�„ lR.
Calmly Parcel IdentiGcationNo.(PIN) 60 ft. 80 ft. Black Hard Clay Dt,ADJIZ�OG W
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 80 ft. 105 ft. Gray Clay
(If well field,one latJlang is sufficient.)
21'REMARKS;,:e.:
35.662969 N -77.510"9 \\'
6. Is(are)the well(s): Permanent -
22. Certification: Cj�r; f{sr:�i 12/8/2022
7. Is this a repair to an existing well: No
Ifdds is a repair,fill a l known well construction information and explain due naure ofthe Signature of Certified Well Contractor Dale
repair under k 21 remarks section or on the back ojthis form, By signing is form,l hereby cent fi•flat the well(s)was(were)cons in accordance
with 15A NCAC 02C.0100 or 13A NCAC 02C.0200 11'ell Construction Standards and#rot a
8. Number of wells constructed: 1 cop),of this record has b een provided to th e well oun er.
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: 176 (ft.)
For mulliple wells list all depths ifd6Terent(example-3@ 200'and 2 @ 1009 SIl11lYI-I Ai•INSTRUCTIONS
10.Static water level below top of casing: 45 (fit) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Ifuater level Is above casing,rise"+^ 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 air 24b.For infection 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'forrit 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): 50 Method of test: Air 24e,For Water Suanh• lniection Wells: in addtion to sending the form to
the address(es)above,also submit one copy of this fort 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 2fM16
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