GW1-2021-04118_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
i
This form can be used for single or mutiple wells
a4. R?A,ES
1.Well Contractor Information: FROM TO DESCRIPTION g
Chauncey Leggett ft. ft.
Well Contractor Name ft. ft.
2269-A 5.O-TER CASING(for ulti-case wells OR ER if¢I ilicab e
NC Well Contractor Certification Number FROM TO DIAMETER TMCKNESI MATERIAL
Lake Valley Well Co., Inc 0 ft 78 It- 6.25 in. SDR21 PVC plastic
Company Name ft. ft. in.
6. RCA IN -O T B]IN G(gent ermal close loop
2.Well Construction Permit#: Gw-045684-2020 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits lie County,State,Variance,etc. ft. ft. in.
3.Well Use: ft ft in.
7.SCRE
FROM TO DIAMETER SS SLOT S MATERIAL
Residential ft. ft. in.
ft ft. in. yy a
..y
,�,•� FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft 2 ft Cnnrrate I Grouting Through
2 ft ftGr)Lgranrouting Through
r rev
ft. ft.
J�. 'Q� ._S /GRA AC (if�applica 1e
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft
ft. ft.
4. Date Well(s)Completed: 5/11/2021 Well ID#
ft. ft.
5a. Well Location: 20. II G OG(a ch ad' itiooal s eets if eces rY
List all applicable well construction pertmits ft County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Drees Homes 0 ft. 10 ft. Tan Clay
Facility/Owner Name Facility ID(if applicable) 10 ft. 50 ft. Tan Sandy Clay
1101 Maduro CT Zebulon 27597 Lot 50 ft. 75 ft. Tan Sandstone
Physical Address,City,and Zip 75 ft. 130 ft. Red Sandstone
Wake 1794841647 130 ft. 362 ft. Gray Granite
County Parcel Identification No.(PIN) ft. fL
5b. Latitude and Longitude degrees/minutcs/seconds or decimal degrees: ft. ft.
(If well field,one lat/long is sufficient.) 21, KS
35.794227 N -78.332042 W Water zones at 135ft,280ft and 330ft
6. Is(are)the well(s): Permanent �q &t
22. Certification: /J -1/,t� O(/
7. Is this a repair to an existing well: No l�Yr 5/14/2021
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 cent that the well(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 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: 362 (M)
For multiple wells list all depths ijdifferent(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 25 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 Service Center,Raleigh,NC 27699-1617
1
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): 5 Method of test: Air 24c.For Water Supply Infection 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: 14 CZ 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