GW1-2021-03879_Well Construction - GW1_20210823

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For Internal Use ONLY:
r WELL CONST i
This form can RlJ!• EFR
R ZO S
6e us�„rmation: TO DESCRIPTION
1.Well_r-•_
o,duncey Leggett ft
Well Contractor Name ft
2269-A ss we 1 O R if a plicab e
NC Well Contractor Certification Number TO DIAMETER THICKNES MATERIAL
Lake Valley Well Co., Inc 105 ft 6.25 1° .188 Steel-galvanized
Company Name ft in.
R oop2.Well Construction Permit!#: E21-000618 TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits(le County,State, Variance,etc. ft ft in.
3.Well Use: ft ft in.
7. G N
FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential ft ft in.
ft ft in.
8.G U
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft
ft ft
ft ft
9.SA / G if a p'ca le
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft ft
4. Date Well(s)Completed: 6/28/2021 Well ID# Perry ft ft
5a. Well Location: 0. G G a c a i'o a eem- I necessary.
List all applicable well construction pertmits ft County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soilh=k type,grain size,etc)
Oakwood Homes of Rocky Mount 045213 0 ft 70 ft Orange Clay
Facility/Owner Name Facility M(if applicable) 70 ft 100 ft Brown Clayey Shale
1869 JP RD Whitakers 27891 Lot 100 ft. 120 ft Brown Rock
Physical Address,City,and Zip 120 ft. 203 ft Gray Rock
Nash 382600511857 ft ft r.9 gym'
County Parcel Identification No.(PIN) ft ft
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft
(If well field,one Iat/long is sufficient.) 21.
36.113632 N -77.899432 W water zone at 140ft 4, .Jrin'UMI
6. Is(are)the well(s): Permanent
Mpg"r•3•Ci;011
22. Certification: /J 1/
7. Is this a repair to an existing well: NO (�Yr 6/28/2021
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 certify that the wells)was(were)constructed in accordance
with 1 SA 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: 203 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100) 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) C
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:
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FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 5 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
13b. Disinfection type: HTH Amount: 12 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
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