GW1-2021-03646_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: NO MIKA MOS NM_
FROM TO DESCRIPTION
Chauncey Leggett ft ft
Well Contractor Name ft ft
2269-A 5.0 ; ER $ for multi-case w Its OR ER ifap licable
NC Well Contractor Certification Number FROM TO DIAMETER TFUCKNESE MATERIAL
Lake Valley Well Co.,Inc 0 ft 127 ft 6.25 in. SDR21 PVC plastic
Company Name ft ft in.
6. RCA G O B (geotherma c o'sed o_op)
2.Well Construction Permit#: 340648 FROM TO DIAMETER TlHCKNESJ MATERIAL
List all applicable well construction pertmits(ie County,State,Variance,etc. ft ft in.
3.Well Use: ft ft in.
FROM TO DIAMETER TMCKNES SLOT SIZE. MATERIAL
Residential �. ft ft in.
y ft ft in.
Q� FROM - TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft 2 ft
75 ft
ft ft
g
(rfaplicabl ;.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft
ft. ft
4. Date Well(s)Completed: 5/12/2021 Well ID#
ft ft
Sa. Well Location: 20. G OG attac ad 'ti na sheetin—s it ecessary�
List all applicable well construction pertmits(ie County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Clayton Homes of Rocky Mount 0 ft 90 ft Orange Clay
Facility/Owner Name Facility ID(if applicable) 90ft. 120 ft Brown Shale
129 Avon Brantley RD Zebulon 27597 Lot 120 ft 282 ft. Gray Slate
Physical Address,City,and Zip ft ft
Franklin 2727-28-5288 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.)
35.88442 N -78.248817 W Water zones at 185ft and 263ft
6. Is(are)the well(s): Permanent
22. Certification: G Y�/,� 00 1
ett-
7. Is this a repair to an existing well: No 5/12/2021
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 wel/(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: 282 (ft)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009
SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 25 (ft)
construction to the following:
Ifwarer 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 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,'Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 5 Method of test: Air 24c.For Water Supply 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: OZ completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16