GW1-2021-04131_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
4. A +ER ZO S
1.Well Contractor Information:
FROM TO DESCRIPTION
Chauncey Leggett ft, ft P
i
Well Contractor Name ft ft
I
2269-A 5.O ER A G for u ti-case we Is O R if applica le.
NC Well Contractor Certification Number FROM TO DIAMETER TIUCKNESE MATERIAL
Lake Valley Well Co.,Inc 0 ft 47 ft 6.25 in. SDR21 PVC plastic
Company Name ft ft in.
6. R AS O G geotherma close oop
2.Well Construction Permit#: 2020-042 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction permits(te County,State,Variance,etc. ft ft in.
3.Well Use: ft ft ! in.
'7. G
FROM TO DIAMETER THICKNES SLOT S MATERIAL
Residential ft ft in.
ft ft in.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft 2 ft
C) v� 2 ft45 ft
ft ft
--------------
7ft
? MATERIAL EMPLACEMENT METHOD&AMOUNT
ft
ft4. Date Well(s)Completed: 5/24/2021 Well ID#
5a. Well Location: 0. G OG(attac ad NOTION'f ecessary
List all applicable well construction pertmits(te County,State, Variance,etc. FROM TO DESCRIPTION(color,hardness,sod/rock type,grain size,etc)
Stone Creek Builders 0 ft 10 ft Orange Clay
Facility/Owner Name Facility ID(if applicable) 10 ft 27 ft Tan Sand
6204 Thombridge Way Wilson 27896 Lot 41 Southpointe 27 ft 40 ft Tan Shale
Physical Address,City,and zip 40 ft 143 ft Gray Slate
Wilson 2794-33-3266 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.) 21.
35.788284 N -78.011203 W Water zones at 57ft, 115ft,and 141ft
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 5/24/2021
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 ONLYwith 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: 143 (ft)
For multiple wells list all depths if different(example-3Q 200'and 2®1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 15 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Ifwater 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): 40 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: 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