GW1-2021-03847_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells _
ASTER ZO.
1.Well Contractor Information: FROM TO DESCRIPTION
Chauncey Leggett ft ft
Well Contractor Name ft ft
2269-A 5.O tER CAS G,(for ul'-case ells OR R f a lica le.
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
Lake Valley Well Co.,Inc 0 ft 83 ft 6.25 i in- .188 Steel-galvanized
Company Name ft ft € in.
16. RCS G O INO ge hernia c se loop)
2.Well Construction Permit#: E20-001134 FROM TO DIAMETER TIUC _S1 MATERIAL
List all applicable well construction pertmtts(te County,State,Variance,etc. ft ft in.
3.Well Use: ft ft in.
FROM TO DIAMETER THICKNES SLOT SIZ RIAL
ft ft in.
ft ft in.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft 2 ft
_LmCrete__ I Grouting Through
ft 83 ft niter
ft ft
9SA, / RA AGK(if plica le
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft
ft ft
4. Date Well(s)Completed: 7/21/2021 Well ID#
ft ft
5a. Well Location: 20. G G a h i'onaI shee i£necessa
List all applicable well construction pertmits lie County,State, Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Michael Langley Construction Co. 009055 0 ft. ­61 ft Red Clay
Facility/Owner Name Facility ID(if applicable) 51 ft 75 ft Cream Shale
199 N Big Woods RD Spring Hope 27882 Lot 75 ft 203 ft. Gray Slate
Physical Address,City,and Zip ft ft
Nash ft ft
County Parcel Identification No.(PIN) ft ft
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft 1 9 ,
(If well field,one lat/long is sufficient.) 21.
35.933188 N -78.135377 W Water zones at 180ft and 192ft
r: U
6. Is(are)the well(s): Permanent
22. Certification: /7 (/O
7. Is this a repair to an existing well: No (� 7/21/2021
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: 203 (ft)
For multiple wells list all depths if different(example-3@ 200'and 2 @/009 SUMITTAL INSTRUCTIONS'
10.Static water level below top of casing: 20 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
If water 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: 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): 25 Method of test: Air 24c.For Water Supply Infection 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