GW1-2021-03853_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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14 W Q17 Eli Z6NES `
1.Well Contractor Information:
FROM TO j DESCRIPTION
Chauncey Leggett - . -
-—--I----- -- _ --..
Well Contractor Name ft. ft.
2269-A _ 5 OtI , 12 GA 1NG fad molt
;,cased wells}OR 'I1ERe(tf applicable
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES$�1_ MATERIAL - -
Lake Valle Well Co.,Inc 0 rf 27 ft 6.25 '" .188 Steel-galvanized
y --- ---- -= -- ---el-----
-----------------------------
Company Name ft. ft. in.'
16.IlV1YE1�CASING OR�1'IJBiN ,t(geotl►ermal,losed-loop);. "' —
2.Well Construction Permit#: E21 000131 FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction petlmiLc(ie C nunly,State, I%ariance,ele•. 'in.
3.Well Use: ft ft I in
FROM_]TO— DIAMETER — THICKNESS SLOT SIZE MATERIAL
Residential ft --- ft_�--------,'in.! — - — —
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-
�18GROCiTT m __
FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
----z ft —Oonorete____ _-__--1-_-.---Grouting-Through.--
et. f rt.�-- �
�_25-_�_-Bentoniteslurry____ 11.__Tremie_P_ipe-.._.__
ft. ft,
_ AiDY I3mPAGK tf aps0c9le�
FROM TO 1 —EMPLACEMENT METHOD&AMOUNT
--
ft. ft.
ACE -- -- -
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4. Date Well(s)Completed: 2/2/2021 Well ID# Tom Jones -
-- — ----- -- -- ft. ft.-I
§a. Well Location: —--
0 gDI2ILT/IN 'T_50G(attachlad�ito»ai�sheets rfgeEessary) _,�
List all applicable well construction pernnitc(ie County,.State, Variance,etc. FROM—�TO DESCRIPTION(color,hardness,soiVrock type grain size etc) —
Cawhitt Farms LLC 32592 --- ---- —
Oft. I 1 ft. I Brown Topsoil
Facility/Owner Name Facility ID(if applicable) 1 ft r 21 ft. i Orange Clay
Bellemy Mill RD Whitakers NC Lot -- L-- --- — — - -���:
21 ft 1 24 ft. Gray CLAY&SHE > , < "
24
Physical Address City,_a n_d_Zip f.jIf.. GrayRock
Nash 0ntiti
County '---------- -A -
Parcel
?
.( ) .�
-- - — - - --- - --- ---
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: Tn
(If well field,one lablong is sufficient.) 21 '�_R S _ s`^ tin
36.140716 N -77.741689 W
Water zone at 140ft�__ _•��'�,.�,r_-�__
6. Is(are)the well(s): Permanent
----- ---- 22. Certification:
7. Is this a repair to an existing well: No (` Yr 2/2/2021
1JYhis is a repair fill out known we//construction iglbrnvation and explain the nature nJ'the Signature of Certified Well Contractor Date
repair under A 21 remarks section or on the hack gjthis form.
Hy signing this 1brm,I hereby certify that the we//(s)was(were)constructed cted in accordance
with 1 SA NCAC 02C.0100 or 15A NC•AC 01C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy ojthis record has been provided to the well owner.
I-'or multiple injection or non-wafer wells ONLY with the same construction,you can 23. Site diagram or additional well details:
subtnit one forms. 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: 192 (ft.)
For multiple wells list all depths ijdiJjerenr(example-3@ 20f1'and 2 r�r 100) SUMITTAL INSTRUCTIONS I
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:Water Quality,/jwater level is above casing,use'��"
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 of W to Mail Service Undergl2 un Injection Control Program,
FOR e following:
WATER SUPPLY WELLS ONLY Division of Water Quality,Under r
Raleigh,NC 27699-1636
113a. Yield(gpm): 10 Method of test: Air 24c.For Water Suo"Iv IniectioniWells: % In addtion to sending the form to
the address(es)above,also submit one copy of this form within 30 days of
where constructed.
!13b. Disinfection type: HTH Amount 12 OZ completion of well construction to the county health department ofthe county
Form GW-I - North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16
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