GW1-2021-04136_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells i
1.Well Contractor Information: 1¢.WATER ZONES
FROM TO DESCRIPTION
Chauncey Leggett ft ft
Well Contractor Name ft ft j
2269-A 35. T ER.CASING for ulti-case wells O R(if applicable
NC Well Contractor Certification Number FROM TO DIAMETER TMCKNES MATERIAL
Lake Valley Well Co., Inc 0 ft 183 ft 6.25 in. SDR21 PVC plastic
Company Name ft ft in.
G O BI1VG gent erma close -loop)
2.Well Construction Permit#: 2020-048 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.
1a7.SGREE FROM TO DIAMETER TMCKNES SLOT SIA MATERIAL
Residential ft ft in.
ft ft in.
own
e a 8V. -RO[3,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft 2 ft
r3� �, v�X ft ft Tremie Pine
a�C1 nt y`r: ft ft
`, !J9 G ATGK(if;appiicabie
,�j `�f Ord'�'✓ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft ft
4. Date Well(s)Completed: 2/22/2021 Well ID#
ft ft
5a. Well Location: 20. G OG(attac ad' itional s Bets if'necessary) '
List all applicable well construction pertmits(ie County,State, Variance,etc. FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc)
Stone Creek Builders 0 ft 18 ft Orange Clay
Facility/Owner Name Facility ID(if applicable) 18 ft 30 ft Orange Sandy Clay
8517 Clearwater Drive Sims 27880 Lot 586 Clearwater 30 ft 95 ft Orange Clay
Physical Address,City,and Zip 95 ft 110 ft. Tan Shale
Wilson 110 ft 170 ft Gray Shale
County Parcel Identification No.(PIN) 170 ft 282 ft I Gray Rock
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft I ft
(If well field,one lat/long is sufficient.)
31. MA ry
35.715547 N -78.145066 W Water zones at 210ft,225ft,235ft and 255ft
6. Is(are)the well(s): Permanent
22. Certification: y1
7. Is this a repair to an existing well: No �" 2/22/2021
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 certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0100 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: 282 (ft.)
For multiple wells list all depths if dierent(example-3@ 200'and 2 @ 100) SUMITTAL INSTRUCTIONS j
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 22 (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
12. Well construction method: Rotary 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): 75 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 OZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2122/16