GW1-2021-00408_Well Construction - GW1_20210129

WELL CONSTRUCTION RECORD For Internal LfseONLY.
hi;!ilrm can he used for single or mutiple wells
I.1\ell Contractor Information:
14.IN ATER ZONES
I k0M TO DESCRIPI ION
Chauncey Leggett
ft. ft.
ki ell Contractor Nance ft. ft.
2269-A 15.OUTER CASING(for multi-casco.wells)OR LINER(if applieable),
NC b\ell Contractor Certification Number FROM -10 DIAMLTFR THICKNESS NIA11RIAL.
Lake Valley Well Co., Inc 0 ft. 36 ft, 6.25 ill. .188 Steel-galvanized
('ontpam Name lit. ft. ill.
16.INNER CASING OR TUBING(geothermal closed loop)
2.1\ell Construction Permit#: E20-001390 I POM tr D \MF Tl 'I? rf f I CK NESS MA f FRIAI.
II'(illl:'17,11'll,/rill!!h'I'llllll,ill( "mill',Slot, I'(ll'l(11k C,.',. ft. f't. ill.
3.\1 ell I.se: ft. ft. 111..
17.SCREEN
FROM TO Dl r Lvi(1 FR THICKNESS SLOT SIZE MA I EiRIAL-
Residential ft. ft. in.
it. ft.
18.GROUT
I RO'M To MAURIAL GMPLACEMLNI METHOD,&AMOUNI'
0 ft. 3 fro Concrete 2 Grouting Through
3 ft. 321t• Bentonite slurry 9 Tremie Pipe
19.SAND/(;RAVEL PACK(if applicable).
FROM TO MA FL RIAI,, EMPLACEMENT METHOD&AM01IN1
ft. ft.
3. Date\\ell(s)C ompleted: 1/15/2021 \\ell ID# Ben Floyd
ft. ft.
5,t. 1\ell Location' 20.DR It,LING LOG(attach additional sheets if necessary)
�Iii. !l uhk❑dlJ,n'?1111.n:lnpuluu11/1C( mI/I blur,, urwnr,'cl,_ FROM TO DESCRII11 ION Irolur.hardness,sod rock type n�m, n slzc.;;te)
Dean Holland Builder 335756 0 f1. 31 ft. Red Clay
i amh!,.(>„nrr Nenu Faellity 11)of applicable) 31 ft. 180 ft. Gray Hard Rock
10512 Seven Path RD Spring Hope 27882 Lot ft. ft.
h,,ic,ll:lddrcss,Cih.and Zip ft. ft.
Nash 284000081324 ft. ft.
vnr. Parcel Idenutic:nfon No 011N! ft. ft.
�h. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft.
'! „ell livid.one I,Itllnnu is su1'ficiem 1 21,REMARKS
35.968429 -78.155731 \\ Water zones at 38ft, 80ft,and 150ft
(,. Is(are)the"Al(s): Permanent
22. Certification
7. Is this a repair to all existing hell: No 1/15,12021
urr,n 0;cpo r.Idl o;n kno,rn lrc/1,un,nvrnun ullnrro,lnnn and explum dlr nuMP(,o11Ar Siprrnue of C'crtified Well Contrarnm Date
: i"M ;nnlrr _'I rrnl,u-A.,,croon or on der hark ill dos I mil. Ht,,/}solo;;da,hwm,i hrlvhr cer/l/1•lbol Ill(,uell(s)ml,Itrere)coil,11'"d 'l ill urcun/uucr
ulllr!?:1 Si.I( oV: .Moll or/ N2t' 0;(I!l II'r!/(unsr171cnn11.17un,lurd,un(llhal u
3I, Allmhfl'Uf Nefls('ItllStrllCted: 1 rohr nJ llnsr(v-+u-,lhn.c Drcn/n•rnidn(rn lhd x,ll utirnrr.
I„r mldl;1, u1lr,Mm ur null-rrunr bell,rJ,A7.L vlllr Ihr,sole uln,lruc-rvun, rat.LOU 23. Site dlagraln or additional Nell details:
a„Polo l,nr You may use the back of this page to provide additional well site details or well
(\ construction details. You mtl also attach additional pages ifnecessary.
1). Filial tt-ell depth helim land surface. 180
r,.-,llq,lr ti;ll, ,/,OIL rrnll(.run116-?(; sumirrkil-INSTRLCTIONs
Ili.Static/rater level helote top()/'casing: 22 (ft.) 24a.For All\\'ells: Submit this form within 30 days ofcumpletion ofwell
construction to the hallowing:
:r, %i n uhnrr(tlsur;�,Ir,r
Division of Water Quality.Information Procession Unit.
1 I, Borehole diameter: 6 (in.) 1617 Mai Service Center,Raleigh,NC 27699-16 1 7
12. \\ell construction method: Rotary air 241). For Iniection NVells: In addtion to sending the form to the address in 21a
Cagle.dnect pu<h.ctc; ahm e_also submit a cope of this lorm within 30 days of completion of-well
constr I000n to the follow in2.
;•(lilt\1 \TF.R St Pill') WFLLS OMA: Division of 1\ater Quality,Undergroun Injection Control Program.
1636 Mail Service Center,Raleigh.NC 27699-1636
'.3;1. 'l field(gpnl): 20 .Method of test: Air 24c.For\\ater Suanh Iniection M ells: In addtion to sending the torm to
the address(es)above.also submit one copy of this tbrm within 30 days of
131). Disinfection qpe: HTH Amount: 12 CZ completion of rkell construction to the county health department ofthe county
where constructed.
I rum(ilk'-1 Norlh Carolina Deparlmcnt of Fimio uneut and Namial Resources - Dirlsion of \Paler Quality Revised_'22'16