GW1-2021-03017_Well Construction - GW1_20210527

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WELL CONSTRUCTION RECORD Rai liscrnul Usc ON1 Y;
This form cbn be owd rar sin&or mWlislo s+ds
1.Wdt Gintractor Information:
to ZONIM
Dylan Fierst iw hi -19D CittPtlrl�
VPdiCofftc(twNantc 27 R 35 ft, PAIR k
4507-A
NCWcUCor» totCertific iouNnmbri 5.a1Fiil Ck1g1tV6 of:"'kiatsiyl `" 4M
Pn0M TO IifAAti7Hit TEIiCRPFSS 14AIMA1,
SAEDACCO Inc 0 n, 25 (. 1" la. SCE-40 PVC
CwtVt")-Nam N R:TUB G? tpt in ltiseA
6ROM im DtVM Mt I TMC'IT'F55 I MAIEAlAL
2.W40FC1on$hmtiDn`Permmlt i ft. rr. ►
l isp all taMM-aWr wt11 prami3s(if.Coamty,StMP,t+oriaWO'1r#emits e1r:1
3.Wdl,Use(¢hock%Tit ltsc): 27:
Wafer Supply Well: FROM 70 OMMKIr" VAT M 'nnC10MRS I MArKMAL
OAgaicuttura) 0municipalf ttblie 25 R: 35 ft, 1" Ib .010 SCH-40 PVC
DGeothenmx(lleadugaCoolingSupply) OR:esidemiai Water Supply(single)
Otndasufal�Commecriai DResidennal Water Srpply wvR01Rt'r, ' �t;.
(shared) PROM To WTF0ttA1 f 1MTP1ACVKMT.MEi 09&AMOUNr
atrri rntiori n, n.
Non Water Supply Well:
abMonitori DReem n. fii.
In c"on Well:
OAgviferlteeharge QOroundwatcrRcnxdiation 1g:StPI ► d f17
[lAgnil�crStotttgcattdxtecav�et} OS:tliniftaarnicr Ptrpvt tArKKrAr; PmiPtn..-W�r
23 n: 35 rA FILTER SAND #2
OAtiuifer Test ostonnnatcr Dminap
ft. iG
0Eytorimenta1 Technology DSdisiik we Co"
20.` 'lilt �1rf1(f h�iifrYilloti>xlsrieN3�xtichtsia ;,
17Caeothenttal(Closed Loop) DTvacer FROM To D-PsMtrraor*&W k*r#nmvw�en
❑Geothenmi(Flea' oli Return) ❑other taylain under 021 Rernaft)
4.Batt Wetl(s)Coniplettd: 5/5/2021 Wc1t1<I1#GP-9
n. (c
Sa.Wdl Location: m n.
EPES Transport System (t. ft.
FacIityd(hvnerNume Fsc041DRfirappikable) a' ��1 2^'�� —
n.
1511 Pleasant Ridge Road, Greensboro, NC, 27409 ztd
n processingP1nsiul Mwss Chy.an Zip 2i _
-77
Guilford Temporary well
Carar+m PAtet9.ldtniit"M110nNo,MIN)
Sb.Latitude and lAngltade in deg csAnimttWscc6ndsor decimal degro : 22.Cet4ifieadnn:
(Uxcnrrekl oneL�9ot�iis�rfliticrA>
36.125339 T -79.961946 W _ 5/4/2021
Raton¢ofCeitificd WdlCozmewr Date
6.is(are)the well(s): ]Permaneat or Memporary
Ur rigrm,e thin foam.l hetrhbr tern jv rho•n,r14s1 wdt{carrel e&whwTe4&r weamanr,r
nick 1M NCAC 021C,01M or 15A NCAC 02C 420111e11ConatnkMon SMndardsan$tw a
7.Ia this ampairtoon existing well: OYC:S or Moo r o�fhermrarrJhnsbter�JrmrhJeelh+akrarllrrnnor.
IfihJa 1x o►+pedr./RJ avi D u•rlJ�orurtsntf�n fq/amaarkat a�i��ptrtin o�c nonare cf ihr i
reprirwaderb21 rem arb xmihm or on the back of thb farm. 23.Stie diagam-or additional well deeds:
You,may use the'back of this pop to proOde addiuotnal nell site details or well
tt.h`rrmberof riclfs cnttctrrtctCd: 1 consnuetlontletarlS: You nMc also fM Ch additional pales if messm%
F uaoutTit/crrdOai or etm-n erer st4ldp tsvJJs dh'/.YntrhtRr rrrmrcaarsmrcrtoar,von rmr 41713M17'1 AL 1PYCTUC LIONS
farm. -.
9.Total pelt depth below land surface; 35 (It.) 2Aa p'or All Wells: Submit tins ifonn vritliio 30 days of oono etion of A*H
forma ftWr wUs ktr ali 41 vks((401eww ter rAple-3@200'mug' @1W) construction to the tottotc ng,
i
10.Statle*A!Aer IMvel below top of casing (ft.) DiFislnaof Water R60iirtea,Information 0"eessing Unit,
I/nritrr keel is obvty easI ag,we"+' 1617 11'latil SmOce C�4n6w.1aleW4 NC 2 7609-1 6 17
11.Rorrhote diameter:2.25" On.) 24b.En inhetian Wdb ONLY: tm,addition to sending the font to the address in
2•ta aboy'e.Aso subnilt a ooyy of this form within 30 ft%of completion of wdl
12.Well corAirim ion mdhod:DPT consmetionto the tbllowing: E
i Le.elm.rotary,cabltdbMpost►ctc.) I
Dh islon of Water-Resoumes,Underground Injection Conft l Pir►gram,
FOR,WATE SUPPLY WELLS ONLY: 1636 MR Smile Getttcr.RSWO.NC 276491636
13a,i''ield(gpm) Alabod of test:
2�For Wafer:SupX!j&Inlorp>t lVl dls:
.Also stibttrt one copy of this form tdthin 0 days of completion or
131)::DIMnfeWon hpe Amount: acil construction to the coamty IwMtb depaitmart of the covaty where
rxmslriictod.
Form MY-1 NorifiCamlinsDgndnv iofEenimnywidandNnnua)Resowccs-Dhi0onaMmaRt9oum Rc�tsed.�l+tg►mt20i3