GW1-2022-08937_Well Construction - GW1_20220919

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells j
14:WATER,Z6NkS aARM
1.Well Contractor Information:
FROM TO DESCRIPTION
Chauncey Leggett ft. ft. i
Well Cont ractor Name ft. ft. I
I
2269-A 15 OUTER CASING_ for muitt-cased wells'OR"I INER ifga licatile""
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
Lake Valley Well Co.,Inc 0 ft. 106 ft. 6.25 in. SDR21 PVC plastic
Company Name ft ft in.
IG-INNER,CASING QR>:TUBING(geo%hernial closediloop) =' t v _-
2.Well Construction Permit#: WP-22-47 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits(le County,State,Variance,etc. ft. ft. In.
3.Well Use: ft. ft. In:
14MCT Rif
FROM TO DIAMETER I TMCKNES4 SLOT SIZ4 MATERIAL
Residential ft. ft. in.
ft. ft. in.
18 ,GROUT , t A ;
i r•r-
FRO r - ._TO A --SMPLACEMENLUETHQD&AMQLW
ft ft. ; '
ft. ft.
ft. ft. I
19 hSANiD;GRA�vEL�PACK(ifsappltcable)
FROM Y TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft.
4. Date Well(s)Completed: 9/12/2022 Well ID# ft. ft.
ft. ft.
Sa. Well Location: 20.iDRILLINGLOG(attach additional sheets rffne scary) m
List all applicable well constuction pertmits Cie County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc)
Jason Morrow 0 ft. 12 ft. Orange Clay
Facility/Owner Name Facility ID(if applicable) 12 ft. 90 ft. Brown Soft Clay
120 N Jacks Drive Macon 27551 Lot 7 Colonels Cove F �' '° a
90 ft 100 ft. Brown Rock y
Physical Address,City,and Zip 100 ft. 282 ft. Gray Rock ..
Warren ft. ft. I
SEP
County Parcel Identification No.(PIN) ft. ft. j
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees:
ft. ft. UrIN
(If well field,one tat/long is sufficient.)
36.53443 N -78.065003 W Water zones at 242ft and 255ft to 265ft
G. Is(are)the well(s): Permanent
22. Certification: ,�q�,�'
7. Is this a repair to an existing well: No //Z';(/(/ 9/12/2022
Ifthis is a repair,fill out known well construction information and explain the nature ojthe ,Signature of Certified Well Contractor Date
repair under#2!remarks section or on the back ojthis form' By signing this jom,I hereby certify that the wel!(s)was(were)conshucted 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: 282 (ft.)
For multiple wells list all depths ifdierent(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 35 (ft.) 245.F.or All Wells: Submit this form within 30 days of completion of well
If water level is above casing,use"+" constmetio to ollowing'
ivision of Water Quality,Information Procession Unit,
11. Borehole diameter: 10 (in.) G17 Mail Service Center,Raleigh,NC 27G99-1617
12. Well construction method: Rotary air 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 form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,IUndergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 25 Method of test: Air 24c.For Water Sunaly 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: 14 OZ completion of well construction to'the'i county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of later Quality Revised 2/22/16