413024_Well Construction - GW1_20130422

` ,Th IV ONICESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environmental and Natural Resources - Division of Water Quality
CERTIFICATION 2269-A
1. WELL CONTRACTOR:
Chauncey Leggett
Well Contractor (Individual) Name
Lake Valley Well Co., Inc
Well Contractor Company Name
STREET ADDRESS P 0 Box 1592
Tarboro, NC 27886
[phone]
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID # Well # 3
WELL CONSTRUCTION PERMIT #
OTHER ASSOCIATED PERMIT # W12-00210
3. WELL USE Injection
DATE DRILLED 12/14/2012
TIME COMPLETED 12:00 AM
4. WELL LOCATION:
City Chapel Hill County Onslow
1506 Velma Road Chapel Hill 52-53 Coker Hills
Street Name, Numbers„ Community, Subdivision, Lot No. Zip Code
TOPOGRAPHIC / LAND SEl I ING:
Ridge
LATITUDE 35.934482 2.7K
LONGITUDE 79.032756 E,rd
Latitude/Longitude Source: GPS
May he in degrees, minutes,
seconds or in a decimal
format
flotation ofwei/must be shown on a USES typo map and attached to this
form if not using GPS)
5. FACILITY
Facility ID #
NAME OF FACILITY
STREET ADDRESS 1506 Velma Road
1506 Velma Road Chapel Hill 52-53 Coker Hills
Street Name, Numbers„ Community, Subdivision, Lot No. Zip Code
CONTACT PERSON Barbara C McDonald
MAILING ADDRES 1506 Velma Road
Chapel Hill NC
Area code- Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 300
b. DOES WELL REPLACE EXISTING WELL? No
c. WATER LEVEL Below top of Casing: 50
Al 3024
d. TOP OF CASING IS FT. Above Land Surface*
Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
e. YIELD (gpm): 40 METHOD OF TEST Air
f. DISINFECTION : Type HTH Amount 12
g. WATER ZONES (Depth)
From 138 To From To
From 250 To From To
From To From To
7. CASING:
Thiclmess/
Depth Diameter Weight Material
From 0 To 20 Ft. 6.25 sdr21 PVC plastic
From To Ft.
From To Ft.
8. GROUT: Depth Material Method
From 0 To 300 Ft. Other Tremie Pipe
From To Ft.
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in
From To Ft. in. in
From To Ft. in. in
10. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
Size/ Material
11. DRILLING LOG
From To Formation description
0 100 Orange Clay
100 230 Orange Sandstone
230 300 Red 8 White Rock
APR 17 Z013
WATER QUALITY SECTIONT
IJFORMATl0N PROCESSING UNi
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS B7PROVIDE0J0 THE WELL OWNER.
SIGNATUR" 4`
Chauncey Leggett
Submit Submit the original to the Division of Water Quality within 30 days. Attn Information Mgt.
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568
12/16/2012