GW1-2021-03851_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal use ONLY:
This,form can be used for single or mutiple wells
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I*.Well Contractor Information: A l�21XJl S w
FROM TO DESCRIPTION
Qhauncey Leggett ft. -ft
---: -_.-._. ...._._... . . .._
Wel I Contractor Name _-_
• _ft. ft. i '
2269-A '1 —fb> m'itt Td 'els x0� (af a pltble
can+m+tz' »•° �e«,:ul ...<kc s ..._. .._
NC Well Contractor Certification Number ,FROM TO ._ DIAMETER THICKNESS, _ MATERIAL_
Lake Valley Well Co.,Inc 0 ft. 141 ft- 6.25 in- .188 Steel-galvanized
Company Name ft ft to
���_�,�,' tN6 OR't"tJli#�'NG�geotiietymsT clb�ed loop) __ _, _
2.Well Construction Permit#: E21-000156
,FROM TO �_ . DIAMETER THICKNESS _ MATERIAL
ell construction pernifs tc( n Stale. 6oriance,etc. in.Lict o!!applicable w _
3.Well Use: ft t in
r
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. : ft in.
in.
•I $��S1lit7CJT x �-'�� t` ',: $'� i_�,# . k tt� .4 ...L� ;: i .,1 � '.: X
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Q ft. z ft. Concrete... . _A Grouting Th.hrough..
2- ft. 120 ft. -Ben tonite slurry. ._ 12 Tremie Pipe
� t`�`'57bIGIiVE•fa3'�(1C.[C(sfap ttcatiih �,,- t . � ''•+
TROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
st
ft ft.
4. Date Well(s)Completed: 1/29/2021 Well ID# - - -
_...
Sa. Well Location: Q DRtlsl3fl (x 3,pG(attkbh'A itrbnshtet9JMcc' ary,,
List all applicable well consiniction penmtta,lie County.Store, N2rionce.etc. ' ' DESCRIPTION y/ro• ty ,etc)
L'„%i�U •
IPTION(color,hardness,soil/rock type,grain size,
Poland Builders 102631 FRO 0 ft., 2 ft. Tan Sandy Topsoil
Facility/Owner Name Facility ID(if applicable)
2 ft
4013 Wallet Mill RD Battleboro 27809 Lot 25 ft Orange Clay
... .. c
25 ft 50 ft. Red Sandy Clay
Physical Address,City,and Zip 50 ft 147 ft. Brown Shale w=
Nash 383300198945 7 14 ft 320 ft. Gray Rock 2Q21
_._ - _ _
Countv Parcel Identification No.(PIN) ft ft.
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft rCO t?
><'xt✓1►�ARKs � ��rl r, Rio
(If well field,one lat/long is sufficient.)
36.052649 N -77.877568 W Water zone at 300ft
6. Is(are)the well(s): Permanent
- 22. Certification:
7. Is this a repair to an existing well: No • UG 1/29/2021
lfrhis is a repair.fill out known well constnicvion information and explain the nolure o/The Signature of Certified Well Contractor Date
repair under-2/remarks.section or on the hack nJ'rhis./nrni.
Rv.cigning thLr,fnrm.d hereby cerli/j%that the welllsy was(were)construct ed in accordance
with I M)V(. :02C A100 or 1 JA NCAC 01C.0100 Well Construaton.Smndardc and that a
8. Number of wells constructed- 1 c•nw'afihis recnrd hos heen provided to the well owner.
J•or rindliple injection nr ruin-water•w•e0.r ONLY with the.came c•on.ctraciinn,i-orr can 23. Site diagram or additional well details:
siehn,ir one forni: 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: 320
For nitilliple wells list all depths ifif SUbTTAL INSTRUCTIONS
; 1 r 1
10.Static water level below top of casing: 22 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
- - construction to the following:
° lfwoter level is se 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 Injection 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:
iFOR 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 Infection Wells: In addtion to sending the form to
" I I -- 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 G W-I North Carolina Department of Environment and Natural Resources Division of Water Quality Revised 2/22/16
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