GW1-2021-03881_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
4. ARZO S
1.Well Contractor Information: FROM TO DESCRIPTION
Chauncey Leggett ft ft
Well Contractor Name ft. It
.2269-A S O T R AS G(fo u ti-case a is R(tf applica M e
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
Lake Valley Well Co.,Inc 0 ft 68 ft 4 in- SCH40 PVC plastic
Company Name 0 ft 143 ft 6.25 in. .188 Steel-galvanized
6. R CAS G O eo erma cI53 d oop
2.Well Construction Permit#: E20-001095 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits(te County,State,Variance,etc. ft ft in.
3.Well Use: ft ft in.
7.SC EN
FROM TO DIAMETER THICKNES SLOT S MATERIAL
Residential 68 ft 168 ft 4 in. PVC plastic
ft ft. in.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft 2 ft Concrete I Grouting Through
ft 35 ft
ft ft
A. AG if pp is e
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft ft
4. Date Well(s)Completed: 7/14/2021 Well ID#
ft ft
5a. Well Location: 20. OG a ac a i'ona hee if necessary
List all applicable well construction pertmits(le County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc)
Kimberly Sykes 335342 0 ft 65 ft Orange Clayey Sandstone
Facility/Owner Name Facility ID(if applicable) 65 ft 250 ft Red&White Sandstone
Richardson Road Spring Hope Lot ft ft
Physical Address,City,and Zip ft ft
Nash 286200751687U ft ft t_t,,I�.� 5
County Parcel Identification No.(PIN) It. It
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft It AUG 12 v
(If well field,one Iat/long is sufficient.)
36.015591 N -78.095096 W Water zone in the screen fro!145ft to
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 7/14/2021
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 well(s)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 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: 168 (ft.)
For multiple wells list all depths if different(example-3Q 100'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: 45 (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
1 ,
12. Well construction method: Rotary-air/foam 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 forin within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Qualiy,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 25 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: 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