GW1-2022-06815_Well Construction - GW1_20220722

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14.WATER ZONES
1.Well Contractor Information:
FROM TO DESCRIPTION
Chauncey Leggett
Well Contractor Name
2269-A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
Lake Valley Well Co., Inc 0 ft. 146 ft 6.25 in. SDR21 PVC plastic
Company Name ft. ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits(ie County,State,Variance,etc. ft. ft. in.
3.Well Use: ft. ft. in.
17.SCREEN
FROM TO DIAMETER THICKNES SLOT SIZ MATERIAL
Agricultural ft. ft. in.
ft. ft. in.
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 2 ft. Concrete 1 Grouting Through
2 ft. 70 ft.
ft. ft.
19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft.
ft. ft.
4. Date Well(s)Completed: 7/22/2022 Well ID# ft. ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(ie County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
kjell Bo 0 ft. 35 ft. Red Clay
Facility/Owner Name Facility ID(if applicable) 35 ft. 100 ft. Orange Clay
18710 HWY 48, Enfeild,27823 Lot 100 ft. 140 ft. Brown Clayey Shale
Physical Address,City,and Zip 140 ft. 340 ft. Gray Rock
Halifax ft. ft.
County Parcel Identification No.(PIN) ft. ft.
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft.
(If well field,one lat/long is sufficient.) 21.REMARKS
36.259703 N -77.86309 W Water zones at 215ft, 245ft,270ft,and 315ft
6. Is(are)thewell(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No (I(J 7/22/2022
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 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy ofthis 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: 340 (ft.)
For multiple wells list all depths ifoli ferent(example-3@a,200'and 2 @a,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-) 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): 25 Method of test: Air 24c.For Water SuIII& Injection 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: 14 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
Page 1

DRILLING LOG(attach additional sheets if necessary) WATER ZONES
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc) FROM TO DESCRIPTION
0 35 Red Clay
35 100 Orange Clay
100 140 Brown Clayey Shale
140 340 Gray Rock
OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
0 146 6.25 SDR21 PVC plastic
INNER CASING OR TUBING(geothermal closed loop)
FROM TO DIAMETER THICKNESS MATERIAL
SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 2 Concrete 1 Grouting Through
2 70 Bentonite slurry 6 Tremie Pipe
SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
Page 2