GW1-2021-04126_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
4.-WAT R¢ZONES a; �g
1.Well Contractor Information:
FROM TO DESCRIPTION
Chauncey Leggett ft. ft.
Well Contractor Name ft. ft
2269-A 3&U ER GAS G(for multicas wells R(if applicab e
NC Well Contractor Certification Number FROM TO DIAMETER TMCKNES MATERIAL
Lake Valley Well Co., Inc 0 ft- 101 ft 6.25 in. SDR21 PVC plastic
Company Name ft ft. in.
6. CAS .G O Gt geothermal c os' loop)
2.Well Construction Permit#: 2021-038 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits tie County,State,Variance,etc. ft ft in.
3.Well Use: ft ft tn.
7.SGR E s
FROM TO DIAMETER CKNESS SLOT S MATERIAL
Residential `,� �� ft ft
ft ft
'8.GROU
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft QrrPt routing Through
ft 101 ft
\f� ROf
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft
ft4. Date Well(s)Completed: 7/21/2021 Well ID# ft
Sa. Well Location: G O ttch d itionsList all applicable well construction pertmits(te County,State, Variance,etc. TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Paradise Homes 5 ft Orange Clay
Facility/Owner Name Facility ID(if applicable) 0 ft Gray Clay
9315 Lefty RD Kenly 27542 Lot 3 ft Gray Shale
Physical Address,City,and Zip ft
Wilson ft ft
County Parcel Identification No.(PIN) ft ft
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft
(If well field,one]at/long is sufficient.)
35.597823 N -78.106077 W Water Zones at 175ft and 190ft
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No � 7/21/2021
lfthis 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,1 hereby certify that the we//(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A 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 oneform. 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: 203 (ft)
For multiple wells list all depths if different(example-3@ 200'and 1 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 6 (ft) 24a.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 push,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): 75 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