GW1-2021-04120_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
]4. A ERZO S
1.Well Contractor Information: FROM TO DESCRIPTION
Chauncey Leggett ft M
Well Contractor Name ft It.
i
2269-A 5.O RCA' G(for u t-.case ells O R,(iftapplicable
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
Lake Valley Well Co., Inc 0 ft. 38 ft 6.25 in. SDR21 PVC plastic
Company Name ft ft in.
R CA ING O UB G geothe ale o e loop
2.Well Construction Permit#: GW-052603-2021 FROM TO DIAMETER THICKNESIf MATERIAL
List all applicable well construction pertmits(ie County,State,Variance,etc. ft ft in.
3.Well Use: ft ft in.
7.SCR "E
FROM TO DIAMETER THICKNESS SLOT SIZ MATERIAL
Residential ft It. in.
in.
FROM �=TO MATERIAL EMPLACEMENT METHOD&AMOUNT
fl s y OJ • ,"��:'��� ft ft rou-
C ncrete tin.
P� ft 30 ft
0� ft ft
.SA /GRA (if;a p icable1 INN'
\� J FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft ft
4. Date Well(s)Completed: 7/7/2021 Well ID#
ft ft
5a. Well Location: 20. G OG attach a itional beets if necessa ,
List all applicable well construction pertmits(le County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
RHC Construction 0 ft 25 ft Orange Sandy Clay
Facility/Owner Name Facility ID(if applicable) 25 ft 30 ft Brown Sandstone
3004 New Watkins LN Raleigh 27616 Lot 14 Watkins Place 30 ft 502 ft Gray Granite
Physical Address,City,and Zip ft ft
Wake 1746686839 ft ft
County Parcel Identification No.(PIN) ft ft
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft It.
(If well field,one lat/long is sufficient.) 21'
35.861488 N -78.505592 W Water zones at 455ft and 485ft
6. Is(are)the well(s): Permanent
22. Certification: cIl
7. Is this a repair to an existing well: No 7/7/2021
If this is a repair,felt out known well construction information and explain the nature of the Signature of Certified Well Contractor Date
repair under tl 21 remarks section or on the back of this form. By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or I5A 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 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: 502 (ft)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100J SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 20 (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: 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): 12 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
18 OZ completion of well construction to the county health department of the county
13b. Disinfection type: HTH Amount: ,
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16