GW1-2022-09423_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 14.WATER ZONE
FROM TO DESCRIPTION
Chauncey Leggett
Well Contractor Name
2269-A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
Lake Valley Well Co., Inc 0 ft. 96 ft. 6.25 in. .188 Steel-galvanized
Company Name ft. ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: E19-000720 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits(ie County,State, Variance,etc. ft. ft. in.
3.Well Use: ft. ft. in.
17.SCREEN
FROM TO DIAMETER THICKNES SLOT SIZI, MATERIAL
Residential ft. ft. in.
ft. ft. in.
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 80 ft.
ft. ft.
ft. ft.
19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft.
ft. ft.
4. Date Well(s)Completed: 7/26/2022 Well ID# Terri Bilotta
5a. Well Location: IF.15M,ING L13G(attach additional sheets if necessary)
List all applicable well construction pertmits(ie County,State, Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Bobby Connie 0 ft. 30 ft. Orange Clay
Facility/Owner Name Facility ID(if applicable) 30 ft. 65 ft. Red Clay
2718 N Halifax Road, Rocky Mount,27804 Lot 65 ft. 90 ft. Brown Clay&Stones
Physical Address,City,and Zip 90 ft. 175 ft. Gray Slate
Nash 175 ft. 180 ft. Brown Slate
County Parcel Identification No.(PIN) 180 ft. 202 ft. Gray Slate
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft.
(If well field,one lat/long is sufficient.) 1.REMARKS
36.000445 N -77.864414 W
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No �J_ 7/26/2022
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 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: 202
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100) 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:
Ifwarer 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 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,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 15 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: 9 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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DRILLING LOG(attach additional sheets if neces
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc) FROM TO DESCRIPTION
0 30 Orange Clay
30 65 Red Clay
65 90 Brown Clay&Stones
90 175 Gray Slate
175 180 Brown Slate
180 202 Gray Slate
OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
0 96 6.25 .188 Steel-galvanized
(INNER CASING OR TUBING(geothermal closed loop)
FROM TO DIAMETER THICKNESS MATERIAL
SCREE
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 80 Bentonite slurry 10 Tremie Pipe
SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
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