GW1--06778_Well Construction - GW1_20230501

WELL CONSTRUCTION RECORD
This form can be used for single or mutiple wells
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit #:
List all applicable well construction pertmits (ie County, State, Variance, etc.
3. Well Use:
4. Date Well(s) Completed:Well ID#
5a. Well Location:
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees:
List all applicable well construction pertmits (ie County, State, Variance, etc.
(If well field, one lat/long is sufficient.)
N W
6. Is (are) the well(s):
7. Is this a repair to an existing well:
8. Number of wells constructed:
9. Total well depth below land surface:
10. Static water level below top of casing:
11. Borehole diameter:
12. Well construction method:
FOR WATER SUPPLY WELLS ONLY:
If this is a repair, fill out known well construction information and explain the nature of the
repair under # 21 remarks section or on the back of this form.
For multiple injection or non-water wells ONLY with the same construction, you can
submit one form.
For multiple wells list all depths if different (example- 3@ 200' and 2 @ 100')
If water level is above casing, use "+"
(i.e. auger, rotary, cable, direct push, etc.)
13a. Yield (gpm): Method of test:
13b. Disinfection type: Amount:
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16
Facility/Owner Name Facility ID (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
(ft.)
(ft.)
(in.)
For Internal Use ONLY:
14. WATER ZONES
FROM TO DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
ft.
ft.
ft.
ft.
in.
in.
16. INNER CASING OR TUBING (geothermal closed loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft.
ft.
ft.
ft.
in.
in.
17. SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
ft.
ft.
ft.
ft.
in.
in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft.
ft.
ft.
ft.
ft.ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft.
ft.
ft.
ft.
ft.ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc)
ft.
ft.
ft.
ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor Date
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
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
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.
SUMITTAL INSTRUCTIONS
24a. For All Wells:Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Procession Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells:In addtion to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Undergroun Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
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
completion of well construction to the county health department of the county
where constructed.
Lake Valley Well Co., Inc
3573-A
Sammy Rackley
E22-001363
Residential
3/8/2023
6187 Dortches Blvd, Rocky Mount, 27804 Lot
Nash
HTH
36.025071 -77.875597
Dean Holland Builder
183
Air8
Rotary air
345791
Sarah and Bryan Keen
Water zones 70ft, 145ft to 155ft, and 165ft
3/8/2023
1
Permanent
6
383300206245
No
12
12 OZ
Page 1
Black Topsoil 30
Red Clay 223
Tan Sand & Clay 4022
Tan Clay 5540
Gray Rock 18355
0 62 Steel - galvanized6.25 .188
0 62 Bentonite slurry Tremie Pipe12
OUTER CASING (for multi-cased wells) OR LINER (if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
INNER CASING OR TUBING (geothermal closed loop)
FROM TO DIAMETER THICKNESS MATERIAL
SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUN
DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc)
WATER ZONES
FROM TO DESCRIPTION
Page 2
Black Topsoil 30
Red Clay 223
Tan Sand & Clay 4022
Tan Clay 5540
Gray Rock 18355
0 62 Steel - galvanized6.25 .188
0 62 Bentonite slurry Tremie Pipe12