GW1-2021-03641_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
.4.W TaER O S.
1.Well Contractor Information: FROM TO DESCRIPTION
Chauncey Leggett ft ft.
Well Contractor Name ft ft
2269-A 5.Oil ER C*ASIN (fo u1H-case m e Is O R if appliea le
,
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES9 MATERIAL
Lake Valley Well Co.,Inc 0 ft 80 ft- 4 -n• SCH40 PVC plastic
Company Name 0 ft. 82 ft. 6.25 in. SDR21 PVC plastic
2.Well Construction Permit#: 328319 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits(ie County,State,Variance,etc. ft. ft in.
3.Well Use: ft ft in.
FROM TO DIAMETER THICKNES SLOT SIZ MATERIAL
Residential ft ft in.
ft It. in.
-
d� FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
vNN\ ft 2 ft rnnrre1 Grouhng Through
c�R A. 2 ft 80 ft j ft ft
ram'c,0
�� 1. .SA ! G (rf a plcable
P JJ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
4. Date Well(s)Completed: 3/16/2021 Well I ft ft.
ft ft
5a. Well Location: 0. G OG attac do al s eets if hecessa
List all applicable well construction pertmits(ie County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
RHC Construction 0 ft 60 ft Red Clay
Facility/Owner Name Facility ID(if applicable) 60 ft 75 ft Brown Broken Rock
120 Sorrell Dr Franklinton 27525 Lot 23 Woodland Park 75 ft 182 ft Gray Granite
Physical Address,City,and Zip ft ft
Franklin ft ft
County Parcel Identification No.(PIN) ft ft.
5b. Latitude and Longitude dcgrees/minutes/seconds or decimal degrees: ft ft
(If well field,one laU sufficient.)
long is sucient.) 21.
a
Water zones at 120ft and 180ft
36.111056 N -78.516011 W
6. Is(are)the well(s): Permanent �.�v,�
22. Certification: /7Yr/� (/(/1
7. Is this a repair to an existing well: No CJ 3/16/2021
If this is a repair,fill 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 back of this form. By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or I5A 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 owner.
For multiple injection or non-water wells ONLY with the same 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: 182 (ft)
For multiple wells list all depths it dierent(example-3@ 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: 15 (ft)
construction to the following:
If water level is above casing,use"+" Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Mail:Servicetenter,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Infection Wells: In addtion to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct push,etc.) above,also submit a copy of this form within 30 days of completion of well
construction to the following:
i
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 15 Method of test: Air 24c.For Water Supply Iniection Wells: In addtion to sending the form to
the address(es)above,also submit one copy of this form within 30 days of
13b. Disinfection type: HTH Amount: 12 OZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16