GW1-2021-03878_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This forth can be used for single or mutiple wells
1.Well Contractor Information: FROM TO DESCRIPTION
Chauncey Leggett ft. ft.
Well Contractor Name ft ft
2269-A O ' ER CyA' G(fo multi-ase Its O R if a p icable
NC Well Contractor Certification Number FROM TO DIAMETER TMCKNES MATERIAL
Lake Valley Well Co.,Inc 0 ft. 56 ft 6.25 j in- .188 Steel-galvanized
Company Name ft ft in.
16. R CAS G eot a maI c10s oop
2.Well Construction Permit#: E21-000441 FROM TO DIAMETER TIRCKNES MATERIAL
List all applicable well construction pertmus ft County,State,Variance,etc. ft. ft in.
3.Well Use: ft ft in.
7.SG N
FROM TO DIAMETER THICKNES SLOT S MATERIAL
Residential ft ft in.
ft ft in.
8.GR0'
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
Grouting Through
ft ft
ft ft
9. A G G if pp ica le
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft ft
4. Date Well(s)Completed: 6/29/2021 Well ID# ft ft
5a. Well Location: 20. G UG s c a ihonal ee 'fne¢essary.
List all applicable well construction pertmits(te County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Joyce Tillery 041447 0 ft 22 ft Orange Clay
Facility/Owner Name Facility ID(if applicable) 22 ft 45 ft Brown Clayey Shale
14847 NC 43 Rocky Mount 27801 Lot 45 ft 85 ft Gray Shale
Physical Address,City,and Zip ft ft
Nash 381600643982 ft. ft
County Parcel Identification No.(PIN) ft ft 9.
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft
(If well field,one lat/long is sufficient.) 21,
36.0719 N -77.5543 W Water zone at 68ft to 75ft
6. Is(are)the well(s): Permanent
22. Certification: � �/Z (/O
7. Is this a repair to an existing well: No Y� 6/29/2021
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,1 hereby certi)�that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or I5A 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: 85 (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: 10 (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 Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 100 Method of test: Air 24c.For Water Supply Infection Wells: In addtion to sending the form to
the address(es)above,also submit one copy of this form within 30 days of
12 OZ completion of well construction to the county health department of the county
13b. Disinfection type: HTH Amount: I ,
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16