GW1-2021-03876_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells j
1.Well Contractor Information:
FROM TO DESCRIPTION
Chauncey Leggett ft ft
Well Contractor Name ft ft
1 :
2269-A 5.O. E A G f r multi case a Is O ER if app�c ble
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
Lake Valley Well Co., Inc 0 ft 43 ft 6.25 in. .188 Steel-galvanized
Company Name ft ft in.
6. R AS O gent erma c se oop
2.Well Construction Permit#: E21-000716 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertmits(ie County,State, Variance,etc. ft ft in.
3.Well Use: ft ft in.
EN
FROM TO DIAMETER THICKNES SLOT S MATERIAL
Residential ft ft in.
ft ft in.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft
1 Grouting Through
ft ft Bentoni' Tremie Pipe_
ft ft
.SA lGRA G rf a ,p ica le
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft ft
4. Date Well(s)Completed: 6/7/2021 Well ID# Evans ft ft
5a. Well Location: 20. G G a ch a itiOWN!s ee 'f necessary.
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 041267 0 ft 20 ft Cream Clay
Facility/Owner Name Facility ID(if applicable) 20 ft 35 ft Brown Shale 4 p
6128 Nicole RD Spring Hope 27882 Lot 35 ft 75 ft. Tan Slate '`a�..�•
Physical Address,City,and Zip 75 ft 183 ft. Gray Rock r%
Nash 276900624485 ft ft. Zj
County Parcel Identification No.(PN ft ft ,
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft
(If well field,one lat/long is sufficient.)
35.924237 N -78.099564 W water zones between 165ft to 175ft
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 6/7/2021
If this is a repair,fill out(mown 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 thin 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: 20 (ft)
construction to the following: i
Ifwmer 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): 80 Method of test: Air 24c.For Water Supply Iniectiou 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.
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/16
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