GW1-2021-05682_Well Construction - GW1_20210727

WELL G NS'TRUMON.RECORD For 1j#MW1 Use ONLY:
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1.Wen Cnatrator inlonva,tion
I4'WTHR .
Rich Lemire rat1M RtZtfiGtetP?tiQN
Welt CorAmw hatild~
2593A ft. R.
NC Wen con"WwrCe"Uhmition wimbc3 '#1t11ER.'Cil ttr �1=n �tIRLillt t tG OCsiltle ..
FROM To P11 SIrTTtt MAnWAL
SAEDACCO Inc 0 fta 30 f4 2" 10. SCH-40 PVC
t"ofmzt4'i`OW MRSAM1t Yf9 "lac
FROM 7@ DEA�TfiR I TMCK ES3 _ 74AI>RFAL
2,Well Construction Permit#: ft, ft. la
f W drlt fireltdte vv'O pm a is o V.cafm v.5wv. ,1{ariasmca,I've+oca err.)
it. f4. im.
3.Wen Vso(ebak a'r11.ase). r30
rt). L44ntirt; SLAMS s t 7KNMS MA IAL
ft. 40 ft 2" ip .010 SCH-40 PVC
SgVtyp Mesidentiat Whter Sttppty(singe) it. %�iir dentlat�tr r Sttpph(shated) ra l+tA 1�rHirttxnaAA1a
0 ft. 26 (L PORTLAND TREMMIE
Non=Wrater Supply Weft:
I&tl4torritctfft� CIRtts�r2'
%"Tectloo Well:
MAgviferRcchargc Retttr"on
xx �
wa u ar n tn€a. a at f At rr'IT tdrMgo-
t3Abltri Or Sttar1�5199��d:R Cekc' f 5 8 rx iv#3arStter 26 (t. 40 (r. SAND #2
ClAquil'er Tc6 13StotmM,ter Drainage
tt. ft.
13E, =iimenW—Teclmotc;y C1subsideraccCofamt
1t11'' � seli-9r1'dtllta+a�' '(_
C3Gapotl tlntti(Clasea Ltulp) E3Trhtet FROM TO a1EiC,Rtt'rt43Stcatar.Mar adeld.aaf4'dueR
Ct eatlfettaral tEleatlf { RetUnt) E30 ter# aift tinder#21 Rel MS) 0 IL 40 ft. SILT/SAPERLITE
R. fal.
.Date WeS(sl+completed: 6-29-2021 Wkj11D#MW-05M
$a.Well"L cation. ft. ft � �^
BATTLEGROUND STORAGE (t ft
FactlityJ0A-nfer Nandi; Facdlit ll)1(if appiicvbrc)
3700 Old Battleground Road, GREENSBORO, NC, 27410
?tgskW rAdd oss 01,and Zip f�• }
GUILFORD BENTONITE FROM 26, TOx28'. %VNU�.
C:ifaaf(x idrrexilal:tdiEisgtiotlNd.(ttk
tb.t.ataitudc and t ngitude is degmeiMinutevsmads tor deciarr► l degrew. 22.Ccetifd�ation:
(if vrell nerd, F,tt,'10LV is su tci id)
. .
T4 a .- .tr t••m.G. 6/29/2021.R -
SigmGlrr otCcaati c r�rFGa1•ataiEmr -" m tioe
6.h(wv)the wt11(S): ZPermaneat Or 137entjKir n &s;rnin,F rhfs f um.I here6).verwy that thr*talus#wru twenef a msrnrcred to«xonfizor
rdarik l-M J CAC 02C,0100 or M MCRG tlaf-,A V Mvis aMamixtret w SAiWtrie cm rdtstt cr
7.Is.this a repair to an existiei well., ElVe s or NNTtt ergrrnf(fidr rrdrzrf ls(tr brrel.rwnrptkrt trl+fv sdrfl+iwrarr,
If*6;its e rp*.jVT out bnmw Wdff`rcmlf:*m-d"o k1ormtrign anal mr10 n r&naradrx,3f Me
re,oarr'r=der-4_I rmarfismjim or rut(far bcal ofthiv fartrr_ 23.Site dingratm or additional well det Ills:
You tuoy use the back of plats pp t0 pt ide additional well site details or well
S.NiumlmirofweiRconstttmd: 1 d ttsttuetiottdhlails. YettmayaLwaftachadalifitoW pages ifnecessin},
free"faMpfe iaryesripn ft#ripe-purer gwy We&ONLY 144 the same aYrarshWfi0 t;mar cam � it 1 .tT1C(i l'C 1°I4N3 ardtsmataxfalm. .,�} IMA
9.ToWvradideplb bebm lan:dsurrartc. 40 (ft.) 244L For_ Wdetlw: Submit this:form ivubm 30 d*s of tonWkniou of vwU
Farr!rd 0,40fe n;v?k liar.rtf der4k$frfifffrd`rtt{cr yate. ;3f°dr(mi 2@ 14,,rA consi talon to the toil miner, i
10.Statle starter lovi below tarp of casing 27 tft 1 Dividou of Water Rexxnurtm lnf€rrmatlon Fror esutftt Unfit,,
1f,owixe k.tvl+s altrave r..a*g dd*e"+" 1617 MAR"Service Cewr4 ftAe0 VC 2116994617
11.Soroople dir mg!(cr:8.25^ tl 241L Fr�ln cm 4 e11v UIsTl.Y: «n additicln to samdifl3 rite form,to the addim in
I4a abihe also stdltttil a eopy Of Haiti farm Nitro -10 days"of completion.of well
ILWWdlgo"St€iR7`doll nWttMd,AUGERS CMstwtionto ilia follonifte:
(te.:sir_raear+.cattle.direct pnk etc-)
DIVMott of♦Pater Resonat car~.Under9ruund tnjeeflon Contrail Program,
FOR WATER SUPPLY WELLS ONLY* 163611 an strVieettttter.Raleigh.NNC 27499-1636
13a Yidld a(�►ni1 Method of rest: 24r.For Water Su &l!a0c inn Wc1ls:
Also Subaru one cop} of this Emotion within.30 days of congAetion of
13b.bisinfeWon tape, .., __ _ Amount:m az well cortntnratian to the emmW health dcpadment of the amrWv x how
coei�m�rs9. �
Fafn1 G1t'' -t N014hCae %M DCPM*drr of fmimmlcl%and NaVW itamumes-1ii+:iiinaaaf Wales RekniC+rr9 Rel ised AVNUSiI 011