GW1-2021-03885_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 14.W.A IERZO S
FROM TO DESCRIPTION
Chauncey Leggett ft. ft.
Well Contractor Name It. ft.
2269-A 35.0 ER GA G for ult-case wells OR R(if applicable
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
Lake Valley Well Co.,Inc 0 ft. 64 ft- 6.25 in. SDR21 PVC plastic
Company Name ft ft, in.
I6. ER GAS O B (geothermal close .oop
2.Well Construction Permit#: 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.
r7 SGR EN
FROM TO DIAMETER THICKNES SLOT S MATERIAL
Residential ft. ft.
ft. ft.
8:'GRO
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
A
ft onset mug Through
ft. entonitp Tremi Pipe
ft. MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft. ft.
4. Date Well(s)Completed: 2/23/2021 Well ID#
ft. ft.
5a. Well Location: 20. G OG(att c ad_ 'tional sbeets'f necessary.
List all applicable well construction pertmits(te County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Brian Cieslinski 0 ft. 12 ft. Red Clay
Facility/Owner Name Facility lD(if applicable) 12 ft. 35 ft. Red Clay&Boulders
215 Wrays Ct Gaston 27832 Lot 35 ft. 50 ft. Orange Clay
Physical Address,City,and Zip 50 ft. 75` ft. Brown Rock
Northampton 75 ft. 322 ft. Light Gray o. '
County Parcel Identification No.(PIN) ft. ft.
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees:
ft. ft.
(If well field,one ladlong is sufficient.) _2LJ.REM'A',R1KS ,a
36.487629 N -77.688208 W Water zone at 75ft
6. Is(are)the well(s): Permanent ^'t 'n
22. Certification: 11 y��-
7. Is this a repair to an existing well: No 1 00 2/23/2021
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 ofthis form. By signing this form,1 hereby cent that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 01C.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: 322 (ft.)
For multiple wells list all depths ifdierent(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 40 (ft)
24s.For All Wells: Submit this form within 30 days of completion of well
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 Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Iniection Wells: In addtion to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct pusb,etc.) above,also submit a copy of this form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 3 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: 16 OZ completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16