GW1-2021-06312_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD Forftlenmi1lsc0N1.Y:
i7ts farm con be u_md for sht lc or nalipk webs �p
i.'W'dlCpntrxctosInformation:
a�V
16NO
Brian Ewing � BR M TO I nK ckli ig
Alelt C'.orAmt(vr Nautk R. R.
4240-B
�.� rer5 $:atrrt l.aaaed" . . b
NCWcllCordYHtYOrCcnffacetiimNnn$c7 O�(1t0ef'�Ott FROM TO FA1% TiIRKRFM MATERIAL,
SAEDACCO Inc �� 0 iL, 18 fL 2.250 ;n. NA STEEL
Canv mg Marne 16s1 ; R:7I)BIN �erfva/ ittseil l
FROM TO I DUNIFTER I THKIMIM I MAIF.RiAL
2.Wcll Construction Permit# R. to. hu.
lift aliapplirndlr wrHPrnnih(ir.Comfy,Sm:r,variawc IrfeEdi n err.)
3.Well.Use(check well uv): t
Water Supply Well: 760
TO pUMKrr:R t r.T ff n 'rir14 MATMIA1.
OAgrknlnuml OMtmicipallmlic : 22 (L1.25- In, .004 NA STEEL
OGeothetn al(Heatingl ooling Supply) OResiden ial Water Supply(Ongla) R to
171ndgshia/CoTnn=ial ORcsidential Water Supply(shared) 3A cROar
FROM TO I MATr:RLlL E1Ht•LSCF.ME4T1NM0DA+AMOUNt
Ofrri Lion R. (L
Non-Water Supply Well:
®Mtruritorin 0ltecas .
Injection well: R. (L
i7AquftRecharge 00roundsraterRemodiation .SAH(b
OAquifcr Stomgc and ftecoviM OSalinity Barrier FROM MAT n Pr11PiJ1 an>•rr wrrtNtn
R. R-
❑Aquifer Test OStommater Dmiangc
0F,sperin=tel TochntolM O sidcncc Cwtval R tL
xa�nitrl,tr1`Ouic a�tet+�radllianDtsttcetl�inetetrsst
OGootiernml(Closed Uop) OTiacer FROM I To attsc�arrio;aewr,hers Ana xtt �t+afa�lc
Ol kodt anal(Head Cooi) Retum) 00thet(egbin wider 021 Remaft) 0 R. 22 iL SILT CLAY PWR
4.Date Well(s)Completed: 8-24-21 WdIIDpGW-s (L R,
Sa.%ell Lreathrn: (L R.
Church Street Medical Center (1. (L
Fecild)')GOWrName Facelit)•MR(if applicable)
R. n.
1126 N. Church St., Greensboro, NC, 27401 R,
Ptpskel Addmss,City.and Zip 31 'iA
Guilford WATER SAMPLE W/SP-22
Cactay Page!Idafdirkmioe NO,(WN)
Sh,l ntitude and IlAngltade in de(pvWminutcs/seconds or decimal degr+ecs: 2L Certification:
(I 011 t)eK ate 110008 is sndfieiced) R
11` W BI"�d n ,E �n 8/26/2021
Si R ffl*d Of WCH Currtlaetor ' m Date
6.Is(are)the well(s): OPerma rem or zTemporary 4 signing dfa foslR l jfew&Avrg r thdi Ar tsY(1((F)ww(wre)e!!/SYtmme j in aMDJtfl6 er
nirh 154 NCAC 02C.01M m 1 SA ArCAC(",C.02(t0 ti 0 Cojurmt M n SmrvW*and dw a
7.Is this a repair to an es3xtirl>;well: oVts or WNo cWrq fh;r arrant h=brm pmvhW ro thr ttwll aamr.
1f thlr R a repatr.,(1ll a®trCrmxra nail corasrnucriaolRJ'rtrrutriA�n mid r�laln the narxre rrf the
repairstrder*21 remaAa aarsian or(An lire hark of this frtrar. 23.Site diagram or additional svell detaft-
1:ou may use the back of
this page 3o prosfde additional nail site details or svell
S.N`nnlber of wells conshveted: 1 construction details, You may also attach additional pages if necessay.
For ow[dpdr 1R 4mi or non•xmer sWply arils ONLY nirh dip atrmr consawrlfarr,you earl
aebM tour farM SUBMITTAL INSTUMONS
9.Total well depth below land surface: 22 24a. For All Wrlii: Sobmlt Ws;d'otrrl within 30 days of completion of nrll
For mmbolr wilt Ho all*pzft4"dWrear(aran.ok-30200'aM?Q1W) Cvnstntctipnto the following:
10.Static water lettl helot►top of casing: (f{.) Division of Water Ressoitret s,Caformstion Processing Unit,
11"Wer kvel asoiboty cvlanc,&W"+" 1617 Mini1 Serviec Ccntcr,Ralelo,NC 276"-1617
11.f%orrhotc diameter.2.25^ (in.) 24b.For jakWall Wells ONLY: In addition to sending rite form to the address in
24a above. also subttlit a oopy of ells forth within 30 days of completion of uvil
12.Well constriralen rpethod• DPT cotuwction to the following:
(Le.aaxr rotary,iabla din d paste,e(c:) f
Mision of Water Resources.v6detgnunnd Injection Control Program,
FOR WATER SUIPPLY WELLS ONLY: 1636 Mat Sm1Ce Civttcr.Ralefglr,NC 2 699-1636
13a,Yidd(gpm) Method of test: 24c.For Water SaItulF&inlcctio iWells:
Also submit one cop} of ihis f6ni within IM days of completion of
13b.Disinfection type~ Amount- well construction to the coumiy he�'altlt depnitment of the county where
constautcd.
Farm G1tr-t Nonh CamW Dzpmitrnm of Em-itomnnd and Natural Rewu mcs-Diil'ision of tlrater Rtsotrm Res•ised AtVAt 2013