GW1-2021-05690_Well Construction - GW1_20210727

WELL CONSTRUCTION RECORD Fnr tatsrrmtml Use ONLY:
Ms form Gn W uSM rer sib or.rr Wb*uc is
1.Wdl Cimtractor.Ltfurmatle r.
;: .. 77
Rich Lemire FROM Y(tI 0WRt Nn
we#t t'auttar N�tn� R, if.
2593A
NCWdlC-6m aorCettificatirrs_Nwnbcx 1 b tf Kf. .t #ci�11
M I T8 VMMrYFR TIMINW-85 HATUT L
SAEDACCO Inc 0 fL 62 rt 21, i SCH-40 PVC
Canvatta'Naotr 1blAtL►R, 'R7118 4Aitli"
FROM To a"SErG9t TnIC NFSS MA7L'RtAL
2.Well C4jngruc*n hrmit 41. ft. rt
rdss a fl Aw eahk wr4peamirx l t.cblwryR S6m:Mori=",Af sceim aura l
R. ri. i71.
3.Watt Uw(elraJ,t well usel mac,
water Stlppli;i ea. V"M. TO.. I PJAMF<. $W.. M,, CCsICY1 S VAU t{tttt t
MAgticRttfunt DMunidpt►1JFttblic 62 ft. 1 72 % 2- in. .010 SCH-40 PVC
Meo t coral(Heotsng(Cooligg Supply) Residential Water Supply(single) tt rt
Ob3dustri►9i#Comamtrial Mesidentiat Water 5uppl�"(sbamd)
t'RObt -, ,b $b LA ,�tkiETIiOD�AlkrO,T;q.T
Olrri [iron 0 R. 57 IL PORTLAND TREMMIE
rilRn water Supply well.
�NEottito ' ❑ rxan ft' �;
eflon 'all: FL
MAtitiWer-Rccharge ClGioupdRatcrltcatodiaaion
t A"Ker Stomp Stud Recavv psalituty,Ranict to bin ,tttnt tn+rat�ftwtrvit 1Mt'rtt0a
60 ft. 72 tt. SAND #2
MAgoWtr TcM l!YM W 19P rt rt,
OEV— mental T=bnotog ❑SASlI Me Control
L]Gettfltett7sai(Closed Loop)
Cr���tatlt:addt tills} sir., � _s' c
oTmce 6ROtt To DBSCRITrM�r.�atd sutlfnMk d7tiNG
043bo wanal(AeafimMCooh Mum) 00ther 1 under#21 Re aft) 0 ft. 68 ft. SILT/SAPERLITE
611 % 72 ft. PWR
4.10Me Wae1i(s)Completed: 6-18-2021 Well Im#MW-05D
tt. #t.
ft WCH Lneatattl: ft. t!. e
BATTLEGROUND STORAGE h ft,
Facelftyd4svmcr Nama FacIily mO{}ratplicabJm ft, ft. �q ..-
3700 Old Battleground Road, GREENSBORO, NC, 27410 rt,
Pbv=d Addom CV.and Zip
GUILFORD BENTONITE FROM 571TO 601 .
Qiia* PArtel hdcniiiloatinikNo.(tom}
Sh.Wi1N�'and Ungitudc in dcginsim-ioutalwcoinds or 6xism. l dcg ccm 22.cerffmMlion:
ftrsr l9 tt td;oft 400t*9S StcfO iGfd)
W _ 6/20/2021
5tgrsttuFc of c,§cltConir for Dalz
6.TS tatr8 dtc�ell(S)r '�rPl'Ytttattt`tlt or UTemporary 8r s*tMg Mir fiorm,f herein errrft rhM.the wrfif rl was(rweM ea mstue}ed in Ucg at ar e
mitt M aVCAC O2C:,Q1M or LTA NCAC 041V.0207 Well C°omonit-cart SraMm4s srnrf±lxrt u
7.U this al repair the as Wafirgncll: t7Ves or &No roprofrl h r!una(kox dnrym t?:mvvrhw ra iI&WH!wier,
If Ahis:b;o rrpcafr,.fife oearkw)m vM1 ern ontalm. )it forpurrrmuwd explrain ffnr moire of rhr
repair wder$21 i rmarkssrcrrms or on thr..bad of fdrix fornt. 23 Site dl3gt'am.or additional wdl dafts
You mW use ft back of fhis page to provide addilimml well site details or well
R.Number of wells cotmtructed: 1 cogslt don details. Yon aw also attach additfonni pam if nec ;
For nwb igkeaimi rrr orvi-nor ph weds 4tVL1'm1rh rhr sarmt eoustrectia+r,your,on
XWMIth a nv foira. .Q.UBMI'CTAL g+ '#'11ONS
9.Totaltcetl depth betotr land surfaeca 72 (ty:} t4a. k*m-A1Melba Suhutit this.farm within Sit days of comolerion of well
For+rwhipJe f !t'srtrlJdagufrc !tw+rrde.+ {rile-3@109,opdM£>f 4:(1ASttllCtonto the fo_no'Mng:
i
10.SWe*%ter lati below top of coingt 27 00 Division of Water Res'on
rem latormation Processing Unit.
/fnnter taW4 is above rdeta .ew"t 1617 mail Scniec Ccntcr,ltsaleiRh,NC 216994617
11.Sore!hole dirtntt her:S.25" On.) 2 ir.Fehr fnl Nns tVe3ia ONLY, In addition to striding die.filran to tlw adds s in
24a abode.also submit a copy of,this foram c+ithia 30 dates of completion of well
12.Knell ctuos auction ntetbod,AUGERS cttuslntetion to the fioliovAng
(i.e.mtpr.nary;cable.direst pnfx em)
Division of Nrn#er Rtsour ;Illtttler)rrtut►d Injaita>a Cantt+al Ftnng°attt,
FOR it ATER SUPPLY 8VEL.S ONLY. 1636 Mall Service Cedrtet;Raldgli.NI C.376"-1636
1i3if Yht1d 2dc.1='oe W;4tyr'Sulu;&En�atniQ VFem.
M) , .�
o # Also submit one wpy of this fit 1 within 30 days of comptietion of
l3b.11h infcutian twp&. Amonnt: - well corutntc0on to the county health depctetmratt of the couto a�h=
- sor�mctcd
Fctfltt tall'-tNwit Catolim t?cga0.MAs or rmammlem AW M3tHsaS tk wwces-DUA as of Maher R tia.*ed AioaMl