GW1-2021-04135_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: FROM TO DESCRIPTION
Chauncey Leggett ft ft
Well Contractor Name ft ft.
f
2269-A 75.0 , ER CAS G for uiii-case wells R(iftapplicable'
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES 4 MATERIAL
Lake Valley Well Co., Inc 0 ft 52 ft 6.25 in. SDR21 PVC plastic
Company Name 0 ft 70 ft 4 in. SCH40 PVC plastic
6. R CASING O IIYG gent ermal closed loop)
2.Well Construction Permit#: 2021-005 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits ft County,State, Variance,etc. ft ft in.
3.Well Use: ft ft in.
e7,SCREE
FROM TO DIAMETER THICKNESE SLOT SIZ MATERIAL
Residential 70 ft 90 ft 4 in. PVC plastic
% ft in.
'd y FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
%-' ft 35 ft utina Thrmigh
remie Popp
ft ft -shmy
SA. / L CK rf pPlicable
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft. ft
4. Date Well(s)Completed: 3/12/2021 Well ID#
ft ft
5a. Well Location: 0. G OG attach ditional s eets f necessary)
List all applicable well construction pertmits ft County,State, Variance,etc. FROM ti TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Jose Rodriguez 0 ft 4 ft Black Sandy Topsoil
Facility/Owner Name Facility ID(if applicable) 4 ft 15 ft Light Gray Sandy Clay&Stones
6532 Dolphus LN Sims 27880 Lot 4 Williams Point 15 ft 42 ft. Cream Sandy Clay
Physical Address,City,and Zip 42 ft 55 ft Gray Slate
Wilson 2783-21-7519 55 ft 70 ft Gray Broken Rock
County Parcel Identification No.(PN 70 ft 322 ft. j Gray Rock
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft
(If well field,one]at/long is sufficient.) 21• S su
35.756543 N -78.047098 W Water zones between 70ft to 90ft and 265ft
6. Is(are)the well(s): Permanent
22. certification: q�
r,
7. Is this a repair to an existing well: No " 3/12/2021
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 ofthis form. By signing this form,I hereby certify 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: 322 (ft)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 10 (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 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): 10 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: 15 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