GW1-2021-03888_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
FIER
1.Well Contractor Information: 4.WATER ZQ
FROM TO DESCRIPTION
Chauncey Leggett ft. ft.
Well Contractor Name ft. ft.
2269-A 5.O GAS G(for multi- axe a is O E"R if a�plicab
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES _ MATERIAL
Lake Valley Well Co.,Inc 0 ft- 63 fL 6.25 in• .188 Steel-galvanized
Company Name ft ft. in.
geot erma close loop)
2.Well Construction Permit#: W20-0269 FROM TO DIAMETT R THICKNES MATERIAL
List all applicable well construction pertmits(ie County,State,Variance,etc. ft ft
3.Well Use: ft ft
7.SCRE N
FROM TO DIAMETER TIMUCKNES SIZ E MATERIAL
Residential ft. ft. in.
ft. It. in.
8.GRO_
FROM a TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft 6ft
ft 63 ft6 Treie Pipe
ft ft
S RA E C if{app ica 1
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft It.
ft ft
4. Date Well(s)Completed: 3/30/2021 Well ID#
ft ft
5a. Well Location: 20. OG(a c ad itiona s e111112 ets 117111 necessary
List all applicable well construction pertmits(te County,State, Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Drees Homes 0 ft 1 ft. Brown Topsoil
Facility/Owner Name Facility ID(if applicable) 1 ft 29 ft Orange Clay
414 Applewood Hillsborough 27278 Lot 29 ft 35 ft Gray Shale �'`• i
Physical Address,City,and Zip 35 ft 182 ft Gray Rock �•� "' .- "
Orange 9876857803 ft ft Q
County Parcel Identification No.(PIN) ft ft p P
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft
(If well field,one lat/long is sufficient.) 2I. MA KS
39.129356 N -79.072059 W Water zones at 75ft with 10gpm and 135ft with 15gpm
6. Is(are)the well(s): Permanent
22. Certification: q�
7. Is this a repair to an existing well: No �" 3/30/2021
If this a 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 certi that the wells)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 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#dierent(example-3@ 200'and 2 @ 100) SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 22 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
If water level is above casing,use"+" construction to the following:
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: 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): 25 Method of test: Air 24c.For Water Supply Iniection Wells:r 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: 14 OZ completion of well construction to
the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16