GW1-2021-04112_Well Construction - GW1_20210823

'.WELL CONSTRUCTION RECORD j For Internal Use ONLY:
a This form can be used for single or mutiple wells
1.Well Contractor Information: 14 WATER ZO 5
FROM ~TO :___DESCRIPTION
Chauncey Leggett - ---- -- _ --Well Contractor Name
2269-A I5 OTER CASING{fob mulct cased wells}OR LINER(if applicable)
- -------- -- ------ _ __... .� ._ .--- -.....
NC Well Contractor Certification Number FROM 1 TO j DIAMETER THICKNESS MATERIAL
Lake Valley Well Co., Inc 0 f[ 113 f[ 6.25 '" SDR21 PVC plastic
Company Name ft ft in
16 INN CASING OR TUBING(geothermal clos oop)
2.Well Construction Permit#: GW-044838-2020 FR M TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertnnits(ic County,State. Variance,etc. ft. ! ft. in,1
3.Well Use: ft. ft. ! in.
FROM TODIAMETER THICKNESS SLOT SIZE MATERIAL
f� ldential
I � a
in.'
- 1
FROM i TO T MATERIAL EMPLACEMENT METHOD&AMOUNT`
^O \ I 0 ft t 2 ft. t _Concrete--_ I—
_ I­ ---Grouting-Through
1. �+^s J��1 ft h ft. a slurry_-._ J Tremie_Pipe_ -
� 2 73 � eentonit
r v�
ti�O� sOC� SAND/GRAYEI PACK(tf applicable)
t� -•r. �' �. .a _
�(} ' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
na•.
l ft. ft I
4. Date Well(s)Completed: 2/15/2021 Well ID# ------ ft
Sa. Well Location: � DRILLING LOG-(at[ach additional sheets if necessary)
List all applicable well construction pertnnits(ic Comny,State, Variance,etc. why — type,gram size,etc) _
!FROM TO DESCRIPTION color,hardness,sod/rock e,
Drees Homes ------ ---- + ---- ---- - - --- - - .__.
Oft 85 ft I Orange Clay _
Facility/Owner Name Facility 1D(if applicable) - -- ' -
85 ft 1100 ft i Brown W/Clay Shale
2105 Old Sorrell RD Apex 27539 Lot The Bluffs at Sorrell Pointe f - -1 0 I — - -
--
ft ft. GrayRock
Physical.Address,City,and Zip
Wake 0780551592 R. ft
l (County, Parcel Identification No.(PIN) f[ ft.
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ! ft. j
(If well field,one IatAong is sufficient.) 21_REMARKS
.35.689156 N -78.713005 W Water zones at 255ft and 325ft
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6. Is(are)the well(s): Permanent ------- - -- --- -- -------_ - --
---------- 22. Certification: ,1i
7. Is this a repair to an existing well: No t f 2/15/2021
lfthis Ls a repair.Jill out known well construction info intation and explain//re nature oJ'the Signature of Certified Well Contractor Date
repair under ti 21 remarks section or on the back of this farm.
13V signing ihis.Jhrnn,1 herehv certify tlin!the well(s)was(were)constricted in accordance
with 15A NCAC.'02C.0/00 or I5A NCAC 02C•.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy nfthis 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: _ 340 (ft.)
For multiple wells list all depths ifdif @
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
construction to the following:
lfwarer 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 Infection Wells: In addtion to sending the form to the address in 24a
(i.e.auger,rotary, above,also submit a copy of this,cable,direct push,etc.) form within 30 days of completion of well
construction
FOR WATER SUPPLY WELLS ONLY: l Division ofWater
IService,ICeodcrgroun Injection Control Program,
1636 'nter,Raleigh,NC 27699-1636
13a. Yield(gpm): 7 Method of test: Air 24c.For Water Supply Iniectiori 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 15 Oz completion of well construction tolthe county health department of the county
-- — -- - --_- J where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16
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