GW1-2021-06305_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD For irterm)Use ONLY:
nh;forrn can be used far aingk or rndtiyk RvVs
1.Well C.onowtor information: 1
``�9 .1 F1rA`t"E1LXY1 �:"i
Brian Ewing PROM TO I P culp'11014
Well contmaw Dame
4240-B � l d reo5�`n�
NC Wdj counworcottirksllon Mmiba ��dJ G..%. S t)tlTfl t/±e1Stl�t3 fr r rHl-eayed vttl OR t N= ttcabk
C TO
SASDACCO Inc $ 0 tf' is (t. 1"A6tiCiKR S ESS PVTERrAL
hL
Compciml A�oere �o Ib 1N1111�R 1$7:OR. Y1B' G t�dWlerfn 4atl
� OM Dim-iFTER irux hNmss MAWRtAL
Z.We11 Censtlusahrn Permit S n. ft, hL
list aft apptirume,u,•il permih(i_r.Crump.Srmr,variswel,1100rflat er.)
n.
3.Well Use(check well use);
Water Supply Well: FROM Tt7 ownrarsR t rsirx. T1rrCUNTI4S MAVOIAl.
Oftdcalftlml OlvtunicipaiftbliC 18 n; 23 n, 1° O10 SCH-40 PVC
lay
CGootberlalal(HeatingCooling Supply') OResidential Water SuppV(singk) n n'
01ndusirtal/Conm ercial OftesidemGal water St tist3RO
4'(sharM) oM TO NATERML RWIACLMINTstL'MOD&AMOLWwr
OIrripstion n. n.
Non-Water Supply Well:
Mivloritoci t7Rcsm n. n.
Injection Well:
OAqutfcrRecharge AGtoundwatcrRcmadiation 1 : . �► .
OAquiferStomp and Rccotery OSalinhy Harrier ®ROM 16 rR. 23 Ft. FILLTERTER i pHpa A ,tk1T Hr rtt n
' SAND #2
13AARiteer Test Q&ommTdcr Drainage
ClExperimcnadTxhnolvg MubsitienceContrril
so�.nR �t3Ilt)i"» �tt,rli.�aaltte��r:�t+�t�tt
OGeotbamal(Closet Loop) ❑Tram 'FROM 1 TO OCSCRtPt3ox aMv br x+limcn rreaeaa
OGeodlermat Qkati Remm) 00dar( lain under#21 Reniafka 0 A. 23 n. SILT CLAY PWR
n. n.
4.Date Well(s)Completed: 8-23-21 WdIID#GW-3 n. 1L
Sur.Well tatcation: rL h,
Church Street Medical Center n ft.
Faw7443%wr Name Far:04 W#(if applictte)
n» n.
1126 N. Church St., Greensboro, NC, 27401 n
Physical Addnss C.W.arAZlp TERM
Guilford Temporary well
f M"h' Paredtd:Nitcatiou No,(PIN)
ft.Latitude and Longitpde in dcgreestminuteslseeonds or decimal degrow. 2L GertHwa inn:
(ttwelt veld,(Ow two"s is 510(3tittrt)
W Briarn..Ewin 8/26/2021
ftIIi n of catl1w Well Cofinactor Daft
6.Is(are)the well(s): OPermwent or WTemporary
fey sfg-4nt'Abt f-ft 1 he-*r'rrO rhet the"W#N)was(«Furl cvntbWed in mwonimtr
nith 15A NCAC 02C.0100 or I SA AICAC MC AZW 11M Constrwrdm SmrreMra's and Ao a
7.h the a repair to an OStieg arch: 0'&'*SL or MNo iWy cftatr nvarrt bm h-m p m*W to tAv m rl oumer.
If 04 Jr a repair.fill orn pant;null conwwvton firforroatW and explain the maire of the
npuir w der021 ffmarat xeruinia er tin the bark of tho farm. 2#.Site d b4vam or additional well der ells
Year ma)'use die bath:of this page to protide additional well Site details of well
8.Numberof tt'elis constracted: 1 construction details. Yea My aim attach additional pages ifnemsary.
For nwNple Jn/ee4tw or eon-wOer s*ph welb ONLY n$rA rhr s m e omstnwilm,yox CM
&vbadtnae form. St313WIMAL INSIUCTIONS
9.Total well depth below land surface: 23 (n.) 24a. F r Atl Wells; Subnit this!fopn A%ithin 3t)auks of eumptdion of srttl
For„mulplewYu:lilt all*p*r(rd�froll aM2CD,147) construction tothc.following:
10.Static water level below top of casinV (ft.) Divislon of Water Resotirtt&Information Processing Unit,
tf nmrer k*wl is aboky rdeing.rare 1617 Mail Service Cl rater.Raleigh,NC 27699-1617
11.t3oreha►[c diameter 2.25° 24b.FbrJ21M11T1 M'gb ONLY: In addition to sending the form to the addrms in
24sabove. also stibmit a copy of ibis form:Lwythin 30 days of completion of Avrll
12.Nell construction action method:DPT Construction to the fotlmtdng:
(i e,siger,rotary,cab►r,diked pub,etc:)
Dhision of Water Resources.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServIce 6rrkr.RaleF);Ir.NC'236"-1636
13s.Ytdd(gpm) Method of test: Zile.For Water SvIOX A4 in�wAtoa'�Vctts:
.Also submit one oW of this form itithin 10 dayx of completion of
13b.Disinfection hpe: Amount- aceli construction to the coamty het(Ith dep0mcm of the county where
cousrractod, {
Fotm GW—t NDA Camllns DapmtnwM of Emiaemramia and Mrutml Resnorocs-Dh kbn of Enter Rmuvs Revised AttPtrst 2013