GW1-2021-03873_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 4. A R ZO S
FROM TO DESCRIPTION
Chauncey Leggett ft ft
Well Contractor Name ft ft f
2269-A 5.U GAS G for n ti a e ells_ O R if a plica le
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
Lake Valley Well Co., Inc 0 ft 105 ft 6.25 1° .188 Steel-galvanized
Company Name ft ft in.
6. R ZDIAMETER
G(geo hecmal c ose oop2.Well Construction Permit#: E21-000195 FROM TO THICKNES MATEList all applicable well construction pertmits(ie County,State,Variance,etc. ft3.Well Use: ft in.
7.sc
FROM TO DIAMETER TMCKNES SLOT S MATERIAL
Residential ft ft in.
ft ft in.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft 2 ft
Concrete I Grouting Through
IL50 ft
ft ft
9. A if pp ica le
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft ft
4. Date Well(s)Completed: 6/10/2021 Well ID#
ft ft
5a. Well Location: (a c a i o al s eets i nee ssa .
List all applicable well construction pertmits(le County,State, Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Poland Builders 335859 0 ft 15 ft Orange Clay
Facility/Owner Name Facility ID(if applicable) 15 ft 30 ft White Sandy Clay&Sand
5117 Joe Ellen Rd Battleboro 27809 Lot 1 30 ft 70 ft Brown Clay
Physical Address,City,and Zip 70 ft 95 ft Brown Shale ;':, a
Nash 383300514477 95 ft 183 ft Gray Slate
County Parcel Identification No.(PK ft ft
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft I ft ;.
(If well field,one lat/long is sufficient.) 2
36.030744 N -77.865529 W Water zone between 160ft to 170ft
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 2/10/2021
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 of this form. By signing this form,I hereby certtA 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 ONLYwith 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: 182 (ft)
For multiple wells list all depths if different(example-3,@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 22 (ft)
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 Servicel Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 20 Method of test: Air 24c.For Water Sunnlv 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: 12 OZ completion of well construction to the county health department of the county
where constructed. i
Fonn GW-I North Carolina Department of Environment and Natural Resources - Division of Wafer Quality Revised 2/22/16
i
I I