GW1-2021-03895_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: J2ANES
Chauncey Leggett FROM TO DESCRIPTION
Well Contractor Name
ft ft
ft ft
2269-A fly UsERCA$�TG`(for mulE�casedells)'OR LAVER(if applicable),
NC Well Contractor Certification Number FROM TO DIAMETER TfflCKNESJ MATERIAL,
Lake Valley Well Co.,Inc 0 ft 63 ft 6.25 'in. 188 Steel-galvanized
Company Name ft ft in.
16 ZNP7ERtCASTGORiTI7BINCs`(geo'thermal closed loop)
2.Well Construction Permit#: W20-0259 FROM TO DIAMETER TMCKNES MATERIAL
List all applicable well construction perhnits(te County,State,Variance,etc. ft ft in.
3.Well Use: ft ft in.
17�SCREENS
FROM TO DIAMETER TMCKNES I SLOT SI MATERIAL
Residential ft ft in,
ft ft in.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft n t S Grouting Though
ft ft eS Pe
ft ft
19 SANp7GRAVEL'PACK(tfrapptcable)'``
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
4. Date Well(s)Completed: 3/1/2021 Well ID# ft ft
ft ft.
a.
List
U st Well Location: 20 D III LING*LUGS attacsheets rf mace"scary).
all applicable well consmretion pertmits(ie County,State,Variance,etc. IRS dttionai�
,..,
Drees Homes FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc)
0 ft 17 ft Orange Clay
Facility/OwnerName FacilityID(ifapplicable) 17 ft 22 ft Gray W/Cobbles Clay&Boulders
1702 Seminole Drive Hillsborough 27278 Lot 22 ft. 600 ft Gray Rock --
'hysical Address,City,and Zip ft. ft
3range 9872477529 ft ft ?_t
,ounty Parcel Identification No.(PIN) ft ft. �3
ib. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft I
If well field,one lat/long is sufficient.)
36.024033 N -79.084669 W Water zones at 330ft with 1GPM and 470ft with 2 t1j, v�.
Is(are)the well(s): Permanent �qo
22. Certification:
. Is this a repair to an existing well: No tJ 3!1/2021
this is a repair,fill out known well construction information and explain the nature ofthe Signature of Certified Well Contractor Date
:pair under H 21 remarks section or on the back ojthis form.
By signing this form,I hereby certify that the well(q)was(were)constructed in accordance
with 1 SA NC.4C 02C.0/00 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
Number of wells constructed: 1 copy of this record has been provided to the well owner.
or multiple injection or non-water wells ONLYwith the same construction,you can 23. Site diagram or additional well details:
rbmit one form. You may use the back of this page to provide additional well site details or well
Total well depth below land surface: 600 (ft) construction details. You may also attach additional pages if necessary.
.
2r multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
D.Static water level below top of casing: 40 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
water level is above casing,use"+" construction to the following:
Division of Water Quality;Information Procession Unit,
1. Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
L Well construction method: Rotary air 24b.For Iniection Wells: In addtion to sending the forth to the address in 24a
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:
DR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
la. Yield(gpm): 2 Method of test: Air 24c.For Water SuDDIV Iniection We'lisl In addtion to sending the form to
the address(es)above,also submit one copy of this form within 30 days of
;b. Disinfection type: HTH Amount: 18 OZ I completion of well construction to the county health department of the county
rm GW-I where constructed.
North Carolina Department of Environment and Natural Resources -Division of Water Quality Revised 2/22/1 1;