GW1-2021-03889_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
OTTES��
1.Well Contractor Information: 14 Wr�TER Z `�.
FROM TO DESCRIPTION
Chauncey Leggett ft ft.
Well Contractor Name ft. ft
2269-A 15 OUTER CASING formulhcased wells zORNEi'(tfaappbcable) .0 400
WN
v
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
Lake Valley Well Co.,Inc 0 ft 63 ft- 6.25 in- .188 Steel-galvanized
Company Name ft ft in.
16:INNER tASN14;OR'TUBING(geott►eritial close Hoop)
2.Well Construction Permit#: W19-0210 FROM TO DIAMETER THICKNES4 MATERIAL
List all applicable well construction pertmits(te County,State, Variance,etc. ft ft in.
3.Well Use: ft ft in.
,
FROM TO I DIAMETER I THICKNESI SLOT SIZ MATERIAL
Residential ft ft in.
ft ft
18;G�20Ufi
FROM TO f s MATERIAL EMPLACEMENT METHOD& . ,.
AMOUNT
ft 3 ftBentonite-dqLgrang Through
ft 55 ft
ft ft
901
=SANDS/GRAVE A Kf(tf appltcabrle" '
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
4. Date Well(s)Completed: 4/28/2021 Well ID# ft ft
ft ft
Sa. Well Location: 30 DRILLING<LOG(attach addtional`sheets if necessary)
List all applicable well construction pertmits ft County,State, Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Cadco Construction 0 ft 10 ft Orange Clay
Facility/Owner Name Facility ID(if applicable) 10 ft 163 ft Gray Rock
1736 Fletcher Bee DR Hillsborough 27278 Lot ft ft
Physical Address,City,and Zip It. ft c;
Orange 9861349206 ft ft Q '
County Parcel Identification No.(PIN) ft ft
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft 31
(If well field,one IaVlong is sufficient.) 21 REMARKS= t>
. _.
35.987231 N -79.121716 W Water zones at 70ft with 30gii at 120ft with 311 and at 160ft with
40gpm
6. Is(are)the well(s): Permanent
2
22. Certification: C 1/���(/(/
7. Is this a repair to an existing well: No f'� 4/28/2021
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 some 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: 163 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 1 @ 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: 40 (ft.)
construction to the following:
lfwater 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
p 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): 100 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:
12 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