GW1-2021-03852_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or mutiple wells
I.Well Contractor Information: 4 WATER ZONES_ONE
DESCRIPTION
Chauncey Leggett
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Well Contractor Name
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2269-A 15 OUTER CASIlYG for molt,cscd we11s)OR L INFR(if applicable)
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NC Well Contractor Certification Number FROM TO i DIAMETER THICKNESS MATERIAL
Lake Valley Well Co., Inc 0 ft.J 80 ft i 4 in. SCH40 PVC plastic
- _ 0 ft. 188 1 Steel- alvanized
9 84 ft. 6.25 i in.
Company Name � �
16)1VIVERICASING OR;TU11VG(geotliecmal closed loop)
2.Well Construction Permit#: E20-001321 FROM TO DIAMETER THICKNESS MATERIAL _
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List all applicable well construction pertmit.c(ie C'ounly.State,
3.Well Use: ft I ft in.'
FROM I TO r- DIAMETER 1 THICKNESS SLOT SIZE MATERIAL
Residential 80 ft. 140 ft 1 4 in.i i PVC plastic
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LFROM TO --I MATERIAL - EMPLACEMENT METHOD&AMOUNT
0 ft ( 2 ft. Concrete__ 1 _ Grouting Through _
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�z_ft. 1 gOft' L_Bentoniteslurry.______12_.___Tremie-Pipe-
FRO ____._
. '. ft ft _
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19 SAND/ORAYEL PACK(rf applicable),; __
M TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
rt-sJ . 1
4. Date Well(s)Completed: 2/1/2021 Well ID# ft. ft.
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------ -- --- ----- -- - ft ft I � i
5a. Well Location: 20 DIED LING LOG(attach addittonalslieets if n'ecessary)�,
List all applicable well construction pernnit.s(le Cnunly,State. Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Joyful Homes 010277 L 0 f� 2 ft. 1 Brown Topsoil
Facility/Owner Name Facility ID(if applicable) 2 ft. 18 ft. ! Orange Clay
12875 Edwards RD Spring Hope 27882 Lot 18 ft.] 45 ft. Brown Clay
Physical Address,City,and Zip 45 ft 1142 ft j Red Sandstone
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Nash 286200510165 I ft i ft
County Parcel Identification No.(PIN) r ft ft ,U1 i1�
n
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: �- ft ft T CP T T
If well field,one IatAon sufficient.) i1 REMARKS - _ _.
( g is su
36.003455 N -78.103115 W Water zone Between 84ft and 142ft
6. Is(are)the well(s): Permanent L -----
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- ------- -- - - 22. Certification:
7. Is this a.repair to an existing well: No 2/1/2021
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1J7his•'ls a repair,,fill out known well construction information and explain the nature gf the Signature of Certified Well Contractor Date
repair under 21 remarks section or on the back of thi.s.forni.
By signing ihisJarnr,I hereby certify that the well(v)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.
l•'or ntuhiple ejection or non-waler wells ONLY with the same construction,you can 23. Site diagram or additional Well details:
submit one forne. 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: 142 _ (ft.)
1--ormrrhiple wells list all depthsifdiJferent(example-3@ 100'and 1 a 100J — -- SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 15 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
!f water level is above casing,use
-- - - - -- --- construction to the following: '
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 on.) 24b.For Iniect161 Wells:$er ce'Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air on 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): 12 Method of test: Air 24c.For Water Supply Iniectionl Wells: In addtion to sending the form to
- the address(es)above,also submit one copy of this form within 30 days of
L131b.-Disinfection type: HTH Amount 12 OZ -- _ where constructed. ± countyo the health department of the county
Fonn GW-I North Carolina D parhnent of Enviromnent and Natural Resourceson of constructionell - Div sion t of Water Quality Revised 2/22/16