GW1-2023-00040_Well Construction - GW1_20230103

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 ft. ft.
Well Contractor Name ft. ft.
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. 88 ft' 6.25 in. SDR21 PVC plastic
Company Name ft. ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: 1924 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.
17.SCREEN
FROM TO DIAMETER THICKNES SLOT SIZE MATERIAL
Residential ft. ft. in.
ft. ft. in.
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 55 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: 11/2/2022 Well ID#
5a. Well Location: 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)
Heather Fullmer 12880 0 ft. 25 ft. Orange Clay
Facility/Owner Name Facility ID(if applicable) 25ft. 65 ft. Cream Clay
56 Perennial Lane, Roanoke Rapids,27870 Lot 65 ft. 80 ft. Brown Sandstone
Physical Address,City,and Zip 80 ft. 90 ft. Gray Shale
Halifax 09-11274 90 ft. 115 ft. Brown Shale
County Parcel Identification No.(PIN) 115 ft. 242 ft.I Gray Shale
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. I ft.
(If well field,one lat/long is sufficient.) 21.REMARKS
36.2651 N -77.4412 W Water zones at 105ft and 230ft
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No �J_ 11/2/2022
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: 242
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100) SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 15 (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): 5 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: 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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DRILLING LOG(attach additional sheets if neces
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc) FROM TO DESCRIPTION
0 25 Orange Clay
25 65 Cream Clay
65 80 Brown Sandstone
80 90 Gray Shale
90 115 Brown Shale
115 242 Gray Shale
OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
0 88 6.25 SDR21 PVC plastic
(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 55 Bentonite slurry 4 Tremie Pipe
SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
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