GW1-2021-03020_Well Construction - GW1_20210527

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WELL CONSTRUCTION RECORD FerlMMOUscON1Y:
' "nil;larm ern be oset!for siTle of mulliple wells
1.Well Contractor Infortuatlon:
ta:'SSriS 7:,U,
Dylan Fierst rRom PrS4'nn'ttl}Y
A"ellcottlr owN:nne 27 ft. 35 n. PWR
4507-A fL
NC Well GoutractorcetritimionNumber 15.OUTER CAMGMY,MftjJ 9td -1h:QR1j'[M.N `tint+
FROM IM I DIAnrMR TMCKI M MAMRIAL
SAEDACCO Inc 0 fi, 25 (t. 1^ gip, SCH-40 PVC
C,nmpnyName f6:'lt�l;�lERiGaCSltilZ313R'7118 Ills' Itised�oii'`
FROM TO 01-Mir m I 71110MIMS MATLIUAL
2.Weil Construction Pe m'it#: ft ft. br
litt aNrtppiirnhlr well prrmits tfx.Cwrnty,Sartre.17tariance.11bCtiat car.)
3.Wdl,Usc(ebeckwell asc):
Water Supply Well: FRU�r TO orAURT1 R SrttYrsuYf Tinrra.7rt MArvtrtAr
®Agricultural Dm6icipalfmlic 25 R. 35 tt 1^ IlkO10 SCH-40 PVC
OGeolbenwl(Heating/Coolirig Supply) 01kesidential Water Supply(single)
01ndustft'Mowiat Mai 171kcsidentiai Water Supply(sbarud) ]A:(iNot39
FROM TO MA7HRtAr. rFIACRMF-�T Art'rilOD t@ AMO
01nigation
Nast-Water Supply Well:
VI monitorin Oltcsm
lii]ect on Weil: ft,
QAgtrifet'Rcchagx (30roundirater ReowdiMon S ><
room 'M PIA tAW. RKP..ACC E ST METit n
13Aquft$tolncAndR&t11wry 0Snlinityaorricc 23 M 35 ft. PILTER'.SAND #2
❑Aquifer Test ostorlmpater Drainage
n. it.
❑Ex;prrimcntnITxhnoloa QStrbsii=cContrvl
1OkDRnAA M LOG hilfikh'vildliftiel3Fiaet i� ersa
13Geotbenllal(Closed Loop) DTraeer FROM l t? DIM"IMOs(C"Pl.kerdn 6014Wn^ a Ift err
❑Genf rival(RentirlrXooli Return) 130119r in under#21 RemadCs)
R. n,
4..DateWcn(s)0ompleted: 5/5/2021 WdiM#GP-7
n. Ir.
Sa rl"ell Laattlnn: ( n,
EPES Transport System n, (1.
FaCililyxhv=Marne Facility U)#(irWplicabte)
n, fa �es!09 9571
1511 Pleasant Ridge Road, Greensboro, NC, 27409 ft. n. WR ser'tovl
F4s9cat AMmss.City.wd Zip .IMM
Guilford Temporary well
Conroy- Plrteet tAePolfittlioes Nb,ln1N)
Sh.Ni tildc and i ongitudc in ticprtcclmlmltcslst Gonda or tkcimai dcFvcs 22,Cerfifrmtiun:
(ttuell Aeld.oircpilots is 8id11C4M)
36,125173 N -79.961032 W 5/4/2021
51 of Ctttlfiad VUc11 Coiittaetor Dasc
6.Is(arc)the vv,dI(s): t2emanent or zTernporary
1�•sfgmfii�that jcmet./hcrrLy eti�Tfi•Md/rhr melfjs•f+amr/aeht)trrtser,mae+d Ire actioi�a>;nr
wh*15A NCAC O7 AIM ear.f SA NCAC MCA2M MU Cowstrwdan SM"dards and that o
7.Is this a repair to in tAsting well: Mcs or M No 4*APy erfth€smrnrf hwbrrn prorkw to aka ur11 pampr.
1f ihls h o repah.,Ufl out hwtw well con amalan i*nwtW emd explain*e nofure njrhe
rrpeirn rre31„emevtis aerdrrm or-rxi tfar Aav1 jihi.M.m 23.Site diatrrarn or additional well dews.
You my rise the back-of this page to proAde additional ttdl site details or well
11.Number of trails constructed: 1 construction details. You may also attach additional pages if imessw.
Fier midalfrlt lie/ertkat ar non-�wiet wpm wrlb O,YLi'nlrh the same raarsww11an,vain can
aadwidt:eau fore, SIMMMUL IlLMCTIONS
9.Total welt depth below land surface 35 (f>,) 24& Par All Well Submit this fonn AA thin 39 days of camytction of stril
form wpietwtun atfdrpa*vIrdiJliwwfe ote jezo 'axw2emY) construction totht:fotlaming:
10.Static waterl"TI below top of"slow (ft,) Division of Water Rtso10 rtes.Intortnation ProcesAng Unit.
tf nutter hurl is drone edd ag om +" 1617 Miki1 Sen ice Cuter.RxIdg ,11C 276994617
t t.Rorehnlc diametce:2 2 5^ 24b.Fite Inkrtlan Welts ONLY: tin addition to sending the forni to the_addnw in
24aabove. also subni t a copy of lilts fomt crilhin 16 days of completion of+aril
t L Well eonsh'ttcdon Foetbod:DPT construction to the followhig:
(Le.Mwr,ramy'vubie direct prtsh.ciel) DhisianofHaterResaRtras,'' Un6er 7tund Injection Control Prograin,
FOR WATER SUPPLY A ELLS ONLY: 1636 Mail Service C ter;RaleW NC'276"4636
13a.Vidd(gpm) lt'Ecdlod of tat 24c.For Water Shcrpl„y do 1n cgk'n:WCIls:
Also submit one copy of this form i%ithin.fit)days of completion of
tab.Disinfection types, Arnount: well constnxtion to the coirnty bc�th depahroc n of the county where
con3tmcled. I
Farm G%V-t Nonh Camfina Depmtuml of Earimmnerd and MnuW Rewtum—D1h*ion*M'&cr Rt Rcv'scd AtVA 2013
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