GW1-2021-03874_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or mutiple wells
-AVER ZO.
1.Well Contractor Information:
FROM TO DESCRIPTION
Chauncey Leggett ft ft
Well Contractor Name ft ft
2269-A O ER S G for u ti-case wel s OR R(if app ica le
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
Lake Valley Well Co.,Inc 0 ft 84 ft 6.25 in• .188 Steel-galvanized
Company Name ft ft in.
6. E AS O- � eothermal c ose oop
2.Well Construction Permit#: E21-000807 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction penmits(ie County,State, Variance,etc. ft ft in.
3.Well Use: ft ft in.
FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential ft. ft in.
ft ft. in.
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
ft 2ft
ft70 ft
ft ft
9.SA_ G G ifap�ica le,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft ft
4. Date Well(s)Completed: 6/9/2021 Well ID#
ft ft
5a. Well Location: 0. G a ac a itional hee 'f eces acy
List all applicable well construction pertmits ft County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Rogers Harris 103285 0 ft 3 ft Brown Topsoil
Facility/Owner Name Facility ID(if applicable) 3 ft 40 ft Red Clay;
992 Cambridge DR Rocky Mopunt 27804 Lot Hampton Hills 40 ft 75 ft Brown Slate '
Physical Address,City,and zip 75 ft 120 ft. Gray Slate ;
Nash 3821132241095 120 ft 125 ft Gray Broken Slate
County Parcel Identification No.(P" 125 ft 282 It. Gray Granite
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft fit}
(If well field,one latflong is sufficient.) 21.
35,979441 N -77.911892 W Water zones at 120ft and 245ft
6. Is(are)the well(s): Permanent
22. Certification: y�
7. Is this a repair to an existing well: No �" L 6/9/2021
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,1 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 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: 22 (ft)
water level is above casing,use
If "+" 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 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): 25 Method of test: Air 24c.For Water SUDDIV 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: 16 OZ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16
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