GW1-2021-03863_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
4. A �FiR ONES
1.Well Contractor Information: FROM TO DESCRIPTION
Chauncey Leggett ft. ft
Well Contractor Name ft ft.
2269-A 5.O E A IN for ulti se we Is R if a placable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESSMATERIAL
Lake Valley Well Co., Inc 0 ft 42 ft 6.25 in- .188 Steel-galvanized
Company Name ft ft in.
R AS G O BI G eo erma close oop
2.Well Construction Permit#: E20-001028 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits(ie County,State,Variance,etc. ft ft in.
3.Well Use: fL ft in.
Z
DIAMETER THICKNES SLOT S MATERIAL
Residential ft in.
ft in.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
IL 2 ft Flpnt 1 Grouting Thmilgh
ft 40 ft' i
ft fL
9.S /- AC tf applicable
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
fL ft
ft ft
4. Date Well(s)Completed: 3/27/2021 Well ID#
ft. ft
5a. Well Location: 20. G OG a c ad itiona sheets' necessary
List all applicable well construction pertmits(te County,State, Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Poland Builders 335441 0 It. 22 ft Orange Clay
Facility/Owner Name Facility ID(if applicable) 22 ft 35 ft Orange Sandy Clay
3345 Striaght Gate RD Whitakers 27891 Lot 35 ft 40 ft. Gray Shale _ }
Physical Address,City,and Zip 40 ft 60 ft Gray Hard Shale c`°
Nash 384500439856 60 ft 282 ft Gray Rock
County Parcel Identification No.(PIN) ft ft
ft ft .1 },
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: -
(If well field,one lat/long is sufficient.) 1. _ S
36.091738 N -83.2494 W Water zones at 210ft,250ft,and 263ft "�'jl
6. Is(are)the well(s): Permanent
22. Certification: yI
7. Is this a repair to an existing well: No �" 3/27/2021
Ifthis 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 1 SA NCAC 02C.0100 or 15A 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 ifdierent(example-3@ 200'and 1 @ 1009 SUMITTAL INSTRUCTIONS
24s.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 10 (ft) construction to the following:
Ifwater 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 Iniection 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): 80 Method of test: Air 24c.For Water Supply Iniection Wells: In addtion to sending the form to
the address(es)above,also submit one copy of this form within 30 days of
136. Disinfection type: HTH Amount:
14 OZ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16
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