GW1-2021-03864_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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1.Well Contractor Information: AST+FR Q S
FROM TO DESCRIPTION
Chauncey Leggett ft. ft.
Well Contractor Name ft ft.
2269-A 1 .O RCS G(for multi-ase wells O ER if applicable)"
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
Lake Valley Well Co., Inc 0 ft 42 ft 6.25 in. .188 Steel-galvanized
Company Name ft. ft. in.
hernia closed oop
2.Well Construction Permit#: E20-001558 FROM TO DIAMETER THICKNESI MATERIAL
List all applicable well construction pertmits(ie County,State,Variance,etc. ft ft in.
3.Well Use: ft ft in.
FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential ft ft in.
ft ft in.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ftI ft
ft42 ft
ft. ft.
9. A, /G L - G (if�applicab e
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft. ft
4. Date Well(s)Completed: 4/7/2021 Well ID#
ft ft
5a. Well Location: pG(a ach additiona a eets if ELI:I ry
List all applicable well construction pertmits ft County,State, Variance,etc. FROM TO DESCRIPTION(color,hardness,sod/rock type,grain size,etc)
Oakwood Homes of Rocky Mount 335708 0 ft 2 ft Black Topsoil
Facility/Owner Name Facility ID(if applicable) 2 ft 15 ft Cream Clay
5643 W Old Spring Hope RD Spring Hope 27882 Lot 15 ft 20 ft. White Quartz
Physical Address,City,and Zip 20 ft. 30 ft Gray Broken Rock
Nash 277900529444 30 ft 185 ft Gray Rock U Y _e
County Parcel Identification No.(PIN) ft ft ri,,r, l t1Zl
Sb. Latitude and Longitude degrees minutes/seconds or decimal degrees:
ft ft �!:i" i9; 1` r +^�,�i oil
(If well field,one lat/long is sufficient.) 1`
35.923843 N -78.067786 W Water zones at 95ft to 98ft, 105ft, 145ft and 165ft
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 4/7/2021
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 ofthis form. By signing this form,I hereby certify that the well(s)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.
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: 185 (ft.)
For multiple wells list all depths if dierent(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 40 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
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 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 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): 100 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
13b. Disinfection type: HTH Amount: 13 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 2/22/16