GW1-2022-04126_Well Construction - GW1_20220425

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VYELL CONSTRUCTION RECORID
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
14.WATER ZONES
�u� n ` f " t J FROM TO DESCRIPTION
Well Contractor Name f ft. ft. `a If tt t /O'
fill b V ft. ft J U
NC Well Contrctor Certification Number I5.OUTER CASING foe mulfl-cased wells OR LINER tf a' licablc
+� FROM I TO DUMETER THICKNESS SIATEItIAL
o ft IL / In. z S y/ C
Company Name 16.INNER CASING OR TUBING eotfierainl'elosed-loo ) (/
2.Well Construction Permit#: oC 1 3 S FROM TO rL DIA THICKNESS :1ATERIAL
List all applicable rill construction perntits r e.Counryt State,Variance,etc.) ft.
t METER to
3.Well Use(check well use):
ft
17.SCREEN
Water Supply Well: FROM TO DIAIIIETER SLOT SIZE THICIGYESS MATERIAL
❑Agricultural ❑Municipal/Public n ft. in.
❑Geothermal(Heating/Cooling Supply) 1416sidendal Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation FROM TO MATERIAL F-MPLACMI N7'METROD&AMOUNT
Non-Water Supply Well: R' 6 fr• �, d Ad owed
❑Monitoring ❑Recovery it. ft
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK If a ticable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑A uifer Test it ft.
q ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control it %
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach:nddttional sheets ifnecessa
FROM TO DESCRIPTION(color,hudnt:ss,snahntk t q In slu eta)
❑Geothermal(Heating/Cooling Rgium) []Other(explain under#21 Remarks) (� it -
4.Date Well(s)Completed:_& 2 - ,2 2 n ft
tt �v
5.Well ft W�Location: ;;�
/-� �S
11b1 lAu i�ubL K /6 ft ft e
;2a6 ft �7`e
Facility/Owner Name Fact•ty ID#(if applicable)
91�5 Z191qR.;tvv7-
nv .2-26 n S-26 iL �e J� d ,1 c l
ft it.
Physical Address,City,and Zip N
n , 21.REMARKSLA 16
County Parcel Identification No.(PM Li
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Mwell field,one lat/long is sufficient) 22.Certification: ^,a
3U. 9y ��� 111--N - 80 20 1 y 2& w ,,;`;i= �_�
- v
�� ture of Certified Wel Conrracto Date
6.Is(are)the vvell(s): lolPermanent or ❑Temporary
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
' with iSA NCAC 02C.0100 or 1S.!NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 6910 copy ofdifs record has been provided to the ivell oiwier.
If this Is a repair,fill out Amotwr well construction inforniation and explain ilia nature of the
repair under#21 remarld section or on the back of this j&m. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Plumber of wells constructed: ! construction details. You may also attach additional pages if necessary.
For multiple h yecrion or non-water stipple wells ON y with Ilia same construction,you can
suubmit one form. 24.Submittal Instructions:
9.Total well depth below land surface:
:26 (ff.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths ifdiiferem(example-3(200'and 2®1000 construction to the following:
10.Static water level below top of casing: T6 (ft.) Division of Water Quality,Information Processing Unit,
lf-mler level is above casing,use '+' 1617 Mail Service Center,Raleigh,NC 276994617
i
11.Borehole diameter: _(in.) 24b. For infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /Tj construction to the following:
(i.e,auger, to�cable,direct push,etc.) '
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:_ !�I 1 R 24c.For Water Sunnly&Geothermal Wells: In addition to sending the form to
1T 'J the address(es) above, also submit one copy of this form within 30 days of
N
13b.Disinfection type: /7 Amount: °.1 iU ^ completion of well construction to the county health department of the county
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