GW1-2021-03621_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD i For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information:
FROM TO DESCRIPTION
Chauncey Leggett ft ft
Well Contractor Name ft ft
2269-A O ER GAS G for ulti leased w lls Q R(if applicable
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
Lake Valley Well Co.,Inc 0 ft 50 ft 6.25 in. .188 Steel-galvanized
Company Name ft ft in.
b. R CAS G OR G eo hernial c ose ,loop)
2.Well Construction Permit#: 83009 FROM TO DIAMETER KNESS MATERIAL
List all applicable well construction pertmits(le County,State, Variance,etc. It. ft in.
3.Well Use: ft ft in.
7. G EN
FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential ft ft in.
ft M in.
8:GROUP
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft 46 ft
ft ft
ft ft
SA /GKIPAC if pp,icable
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft ft
4. Date Well(s)Completed: 7/21/2021 Well ID#
ft ft
5a. Well Location: 0. G OG attac additiona 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)
Will Johnson Building Co. 0 ft 15 ft Orange Clay
Facility/Owner Name Facility ID(if applicable) 15 ft 25 ft Brown Rock F`�
357 Riverwalk Trail Pittsboro 27312 Lot 25 ft 100 ft. Gray Broken Rock
Physical Address,City,and Zip ft ft .,y.
Chatham 83009 ft ft q
County Parcel Identification No.(PIN) ft ft s• r
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft r ^� CJJr'sOr
(If well field,one lat/long is sufficient.) Zl' $ (ijorNIMMAIWASMI
35.78172 N -79.151958 W Water zone is 80ft to 100ft
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No � 7/21/2021
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 we/l(s)was(were)constructed in accordance
with 15A NCAC 02C.0/00 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: 100 (ft.)
For multiple wells list ail depths if different(example-3@ 200'and 2 @/009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 65 (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 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): 10 Method of test: Air 24c.For Water Supply Infection Wells: In addtion to sending the form to
the address(es)above,also submit one copy of this form within 30 days of
12 OZ completion of well construction to the county health department of the county
13b. Disinfection type: HTH Amount: y
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16