GW1-2021-01413_Well Construction - GW1_20210827

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 14.WATER ZONE
FROM TO DESCRIPTION
Chauncey Leggett ft. ft.
Well Contractor Name ft. ft.
2269-A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicabl
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
Lake Valley Well Co., Inc 0 ft. 70 ft- 6.25 in. SDR21 PVC plastic
Company Name ft. ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: 8601 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.
1
FROM TO DIAMETER THICKNES SLOT SIZ MATERIAL
Residential ft. ft. in.
ft. ft. in.
18.GROL
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. 2 ft. cnnrretp I Grouting Through
2 ft. ft.
ft. ft.
19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft.
ft. ft.
4. Date Well(s)Completed: 8/19/2021 Well ID#
ft. ft.
Sa. 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)
Shawn Perry 0 ft. 4 ft. Brown Topsoil
Facility/Owner Name Facility ID(if applicable) 4 ft. 40 ft. Brown Clay
195 Pritchett Lane, Warrenton, Lot 40 ft. 65 ft. Brown Shale
Physical Address,City,and Zip 65 ft. 80 ft. Brown Slate
Warren 80 ft. 160 ft. Gray Slate
County Parcel Identification No.(PIN) 160 ft. 283 ft. I Gray Granite
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft.
(If well field,one lat/long is sufficient.) 2
NWAIM
36.26635 N -78.234254 W Water zones at 175ft,215ft and 230ft
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 8/19/2021
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 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 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: 283 (ft.)
For multiple wells list all depths ifdierent(example-3@ 200'and 2 @ 100) SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 20 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
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 Injection 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): 5 Method of test: Air 24c.For Water Supply 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