GW1--04879_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14.WATERTZONES ►'s -. _ .I.Well Contractor Information:
FROM TO DESCRIPTION
Sammy Rackley _ ft. ft.
\Yell Contractor Name ft. ft.
3573-A ly OUTERrCASING'.(fo,mom ult� •ed,welLs);OR3LINGR7fifiapplicatili)
NC Well Contractor Certification Number FROM TO DIAMETER. THICKNESI MATERIAL
0 ft. 72 fL 4 itt, sch 40 PVC plastic
Lake Valley Well Co„Inc -
ft. ft. Its.
Company Name �th
16.INNER_CAS4dG 71;=. ING(geoermal close_
d p)
2.Well Construction Permit#: PWS2023-100813 FROM TO DIAMETEF. THICKNESS MATERIAL
List all applicable well constructionpertmits lie County,State,Valiance,etc. J it. ft. i:t.
3.Well Use: ft. ft. ill.
17!SGREEN -.
FROM TO DIAMETER THICKNES SLOT SIZ MATERIAL
Residential 72 ft. 92 ft. 4 in.I PVC plastic
ft ft. in.!
18:GROUT -
FROM TO MATERIAL EMPLACEMENT ME IIOD&AMOUNT
j 0 ft. 2 ft. Dry granular entn
2 ft. 65 ft. Bentonite sin Circuit pipe oracle
ft. ft.
!9SANDG1AVEL�PaCKr(if licable) _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT 1
I
65 ft. 92 ft.#2 Filter Sanc, Other
ft. ft.
4. Date Well(s)Completed: 6/25/2024 Well ID# ft ft --
5a. Well Location: 201DRIL'LING}Lr0GI(attach adiiitional'sheets if necessary)
List all applicable sell construction pernnies Ile Carty,State,Variance.etc. FROM TO DESCRIPTION(color,hardness,soit/rock type,grain size,etc)
Albritton Construction INC 0 ft. 4 ft. Black Sand/Topsoil
FactlityiOwnerNasne Facility ID(if applicable) 4 ft. 15 ft. Orange Clay
4283 California Rd Farrnville 27628 Lot 15 ft. 25 ft. Gray Clay
Physical Address,City,and zip 25 ft. 32 ft. Gray Fine Sand S"
Pitt 32 ft. 45 ft. Fine To Medium Sand
Cosmty Parcel Identification No.(PIN) 45 ft. 50 ft. Gray Clay D'.;�...
5b. Latitude and Longitude degreeslmioutes/seconds or decimal degrees: 50 ft. 90 ft. White Fine To Medium Sand
Orwell Geld,one lat/longis sufficient.) 21!}RE MAR KS
35,623877 N -77.579868 W -
6. Is(are)the wcll(s): Permanent 22. Certification: ,Sy,e., }ti1CI-t°
7. Is this a repair to an existing well: No - i4- 6/25/2024
If this is a repair,Jill 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 bark of this farm. By signing this form,'hereby tenth,that the wells)Nor(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA 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 onner.
For multiple injection or non-outer sells ONLYnith the sonic 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: 92 (ft.)
For multiple wells list all depths if different(example-3Q 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: 10 (ft.) construction to the following:
If water level is above casing,use'+- Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 4 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary-mud 24h.For Infection Wells: In addtion to sending the form to the address in 24a
(Le.auger,rotary,cable,direct push,etc.) above,also submit a copy of this foim within 30 days of completion of well
construction to the following:
IFOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Ilndergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 50 Method of test: Air 24c.For Water Supply Injection Wells: In addtion to sending the form to
I the address(es)above,also submit one copy of this form within 30 days of
I3b. 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 Wtdcr Quality Revised 2/Z2/16