GW1-2021-00404_Well Construction - GW1_20210129

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WELL CONSTRUCTION RECORD for lmanai use ONI'y
This form can be used for single or mutiple wells
14.WATER ZONES
1.Well Contractor Information:
DRUM In DE SCRIP II(JV
Chauncey Leggett ft. ft.
Well Contractor Name ft. It.
2269-A 15.OUTER CASING(for multi-eased wells)OR LINER(if applicable)
NCW'ell ContractorCertification Number IR(IM to 1)L NIfFtR DII(RI:LSS M.%ILRIA1
Lake Valley Well Co.,Inc 0 ft. 88 ft- 6.25 in- SDR21 PVC plastic
Colnpam Name ft. ft. in.
16.INNER( IOSING OR I I BING(geothermal closed loop)
2.Well Construction Permit#: 335670 1MAI I, Itov%II It II If(R,k PSS MA[I_RIAL.
,,.lull, ...No.'0/Oon"'.annpemnm pef l+un(It Vale.I nuance.rrr ft. ft. in.
3.IN elf Use: ft. ft. in.
17.SCREEN
IR.IAI IO 11 NIFftIt THIR KNISS SOIITSI/F- MAILRIAL
Residential It. ft. in.
in.
18.GROt'T
IROM l0 6LUF:RIAL EMPLA(I NP N r MPII (A)&AMI HNI
0 ft. 2 ft, Concrete 1 Grouting Through
2 ft- 50 ft' Bentonite slurry 4 Trernie Pipe
ft. it.
19.SAND/GRAVEL PACK(if applicable)
. _ .
iR:ill li, Mi Afi121.11. @MPLVCEMENT MGI ill iDk.AMORN I'
If. It.
It. It.
4. Date Well(s)Completed: 1/21/202.1 Well IDH
fit. ft.
5m. Well Location: 20.DRILLING,LOG(attach additional sheets if necessary)
/eIt ap arrd"able.-,It'onvruainnf'rrnn1,nr('mm1I,Vale, I ir.w.c1c PROM T(I DGSCRIPIICI^l wnlor_Inuln,s , ,. dr,,,l h„
I elr
RHC Construction .
0 ft- 70 file -Orange Clay
1..rhI,t noler Nan.: Facility ID ol'appheabtel 70 B. 80 fit. Brown Shale
-90 Mulberry Rd Spring Hope 27882 Lot 80 D. 182 ft. Gray Rock
I'b,crcal Address,C'iw,and 7.ip ft. ft.
Forsyth 2738-58-0783 ft. ft.
( .mly Pam]Identification No (PIN) ft. It.
5b. Latitude and Longitude degrees/minutes/seeonds or decimal degrees: ft. ft'
21.RENI:IRKS 'is ^, • �.,JPy .�.'9, � r.
111'wrll field,one lar/Iong is sufHcieor, .^ �s
35.915128 N -78.206355 W Water zones at 90(t to 115ft and 14Sft
6. is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 1/21/2021
II dn,n a r..Jmo,hl/oar krman...It[mr-,Im.nun n./nnneniun nnJ u.rplarn the nmar'e u/I/re signature of Certified Well Contractor - Dale
r gnu,unJer' 1!renrdrka mx'liaa ur cur Jrr hart ul Ihr-r/Jrrn- Qv riguurp dn,brrnr.Iho,'m rrrnli dOol Jre 111(16l r ve N.ml 1110 nerlcd m u<c urdmru'
.11,1SI.Y(dl'rl2( OPH)ur l:,I 4(:a('o2r J0011Irr1/(le..po"mr clarxlanlI and Jon u
k. Number of w'ellscoustructed: 1 cape ullhrs re<ultlhos Aecp I...../rd Or,lh, 0,,1 ,mar
l',ain..hrple rniervunorvnur.......r.ell,OA'I I o ah the,,ante mrwnvdbat%aa tun _ 23. Site diagram or additional well details:
v/'^^r .0,i,ml_ You may use the back of this page to pro ide additional well site details or well
construction details- You mat also attach additional pages ifnecessar}.
9.Total well depth below land surface: 182 (ft.)
1ura,.hpk .ell,1,vo11de/alurr,h71uxva k<✓mplr-3a 200'wid 252100I, !� L4�� SI'MI7TAL INSTRI'CTIONS
L 24a.For All Wells: Submit this toms within 30 dos of completion of well
I11.Static water level below lop of casing: (>0 �p,N f (ft.) 24a.
to the following:
Division of Water Quality,Information Procession I'll
11. Borehole diameter: 6 (in.) - 1617 Mail Service Center,Raleigh.NC. 27699-1617
12. N ell construction method: Rotary air 24b.For Infection Wells: In addtion to sending the fort to the address in 24a
U.e.anger.rotary,cable.direct post,.ewr above.alho,uhnot a cop%of this toot within 30 days of completion of well
construction to the tbilowing:
FOR WA7"ER SUPPLY WELLS ONLY: Division of N'ater Quality,Cndergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 60 Method of test: Air 24c.For Water Sumaly Infettion Wells: In addtion to sending the Brim to
the addressles)above.also submit one cop)of this form within 30 days of
13b. Disinfection type: HTH .Amount: 12 OZ completion of well construction to the count) health department of the count%
where constructed.
Donn Gw-I North Carolina Department of Environment and Natural Resources - Ufa 1I of Water Qm,bty Rcsised 1'22 11,