GW1-2021-03854_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
E� GA
1.Well Contractor Information: DESCRIPTION
Chauncey Leggett ft.
Well Contractor Name ft2269-A (for ulti-casetl ells O if applicable
NC Well Contractor Certification Number DIAMETER THICKNES MATERIAL
Lake Valley Well Co., Inc ft 6.25 in• .188 Steel-galvanized
Company Name ft in.
G O IN (geotherm close loop
2.Well Construction Permit#: E20-000930 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits(te County,State, Variance,etc. ft ft. in.
3.Well Use: ft ft in.
;';'
DIAMETER THICKNES SLOTS MATERIAL
Residential t in.
t in.
MATERIAL EMPLACEMENT METHOD&AMOUNT
t t ronrrete 1 mis nq Through
ft 90 ft entonites Tremie Pine
ft ft
S / C if applicable
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft ft
4. Date Well(s)Completed: 3/11/2021 Well ID#
ft ft
Sa. Well Location: 0. G OG(a c additional eels if necessary
List all applicable well construction pertmits(ie County,Stare, Variance,etc. FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc)
Paradise Homes 335873 0 ft 30 ft Red Clay
Facility/Owner Name Facility ID(if applicable) 30 ft 80 ft Brown Clay
3749 Old Nash RD Middlesex 27557 Lot 80 ft 100 ft. Brown Shale
Physical Address,City,and Zip 100 ft 182 ft Brown Slate
Nash 275700131559 180 ft ft
County Parcel Identification No.(PIN) ft ft i!r'tJVlI
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft
(If well field,one lat/long is sufficient.) Z1
35.872586 N -78.152613 W Water zone-at 162ft
6. Is(are)the well(s): Permanent
22. Certification: 1/,� �/O
7. Is this a repair to an existing well: No G y( 3/11/2021
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 t!21 remarks section or on the back of this form. By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 1 SA 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: 182 (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: 22 (ft)
If water level is above casing,use"+° construction to the following:
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 Injection 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,jUndergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 20 Method of test: Air 24c.For Water Supply IniectionI Wells: In addtion to sending the form to
the address(es)above,also submit one copyof 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 I
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16