GW1-2021-04130_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 4: A 3FrR ZO S
FROM TO DESCRIPTION
Chauncey Leggett Ft It.
Well Contractor Name It. ft I,
2269-A 5.O ER S G(for Ar a e we Is O Ica e
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
Lake Valley Well Co., Inc 0 It. 84 ft 6.25 in. SDR21 PVC plastic
Company Name ft ft in.
1 . ­$J11N INGNgeot erma close oop
2.Well Construction Permit#: 2021-035 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits(ie County,State,Variance,etc. ft ft in.
3.Well Use: ft ft in.
7. G
FROM TO DIAMETER THICKNES SLOT SI# MATERIAL
Residential G' ft ft in.
a,'*^
ft ft in.
8.XAJ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
��, J r•� 0 ft 2 ft rnnrrete I Grouting Through
rU0 ft 80ft
c<t ft ft
Wx>' Q 1 / G if a plica le
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft ft
4. Date Well(s)Completed: 5/24/2021 Well ID# Artrip ft ft
5a. Well Location: 20. G OG(a ch bona sbeets if ecessa.
List all applicable well construction pertmits ft County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Stone Creek Builders 0 ft 25 ft Orange Clay
Facility/Owner Name Facility ID(if applicable) 25 ft 30 ft Tan Sandy Clay&Sand
6205 Thombridge Way Wilson 27896 Lot 42 Southpointe 30 ft 75 ft Brown Shale
Physical Address,City,and Zip 75 ft 500 ft Gray Slate
Wilson 2794-33-3495 500 ft 520 ft White Quartz
County Parcel Identification No.(PIN) 520 ft 603 ft Gray Slate
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft
(If well field,one lat/long is sufficient.) 1•
35.789048 N -78.01099 W Water zone at 510ft
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 5/24/2021
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 certo 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: 603 (ft)
For multiple wells list all depths if different(example-3Q 200'and 2 Q 100) SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 15 (ft.)
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 Infection 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): 2 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: 18 OZ completion of well construction to the county health department of the county
where constructed. I
Form GW-I North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16
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