GW1-2021-06314_Well Construction - GW1_20210915

WUL CONSTRUCTION RECORD Partr'lsmirtuscUNLY:
Mds form cn."W xwd for simb"atnletple was
1.Well C.outntaor iuformsdow
Brian Ewing Ap GROIn TO -. DrsCTIPITON
a ft. ft.
11dtCoi�#+.ucturt?>4trK
�Cj ���` fG ft,
4240-B `�
NC ls'WdJCan MrCcnifh�tiuuNwrdcr , a5�� t3t7TFa1t A.41Crf nr " ii�etaeglesreit "flR':L fi,R b
�r f re;" M TO IASIETRft M MAMRIAL
SAEDACCO Inc "Q �� �r ' 0 ft. 22 fL 2.25" ! te, NA STEEL
cftapa"';'Main.
FROM 170 1OLi4fEfliR TIiICKnRSS MATERIAL
2.w'e)Cons trmxion Permit
6istafi fixuraNe,frrfr ptMos a r.Cmmry.Saar,Varian re,Tri vl sfr)
(L fb
3.Wdl.l sc(ebeek w ll use):
Witter Supply'Well: PROM TO mAWW..R I 61AMSFU I arflC*NWS I a+ mans,+
I Apricttlttlred GtMtrnisipaltAttblic 22 !t: 26 N 1.25° 1ft .004 NA STEEL
OGeothennai(lietititt}iCoofifrg Supply) 01tesidential Water Supply'(singles
13mustrialtGonutimial 171tesidential WriterSttpply(ftred) t [3Hb
6'ROM TO iFIATRRIAI. R.f AC£MM'VM M0D R AMOUNT
Olm'.Chin ft. ft.
Non-Water Supply Well:
Z�Maaritori t]ltsco� ft. (t,
Injection Well:
DAgnifer Recharge OCirouriftmtcr Retried ation
OA; uftrS(omgc and Tern vy OSalinity carrier t rt. t wi art tier t-r n .
tYR M IATltitt
OAquifer To OStommatcr Dwriage
ft, ft,
OFxpcdoicntal Trchnoto t O$trbsidtar�c Control
2ti. '(i2t1 xftrerli�drttrtimlit' air" �
❑Geod"nal(Closed Loop) OTrace r FROM TO IDESCItt oN' sr, �n�srrti csr
oGeotbemud 01tatitigodiM Renim) ci0ther(Mlaintifkkr#21Remaths) 0 ft. 26 fL SILT CLAY PWR
ft. ft.
4.DatcWe1l(s)C6mplefed 8-24-21 wV]D#GW-10
ft. tt.
Sa,%Veil Lnellllm: IL tt.
Church Street Medical Center fb ti.
Facu7itt rencr Nxrric FxcilFtt IDlf(if a�itiwblt) fL
11.
1126 N. Church St., Greensboro, NC, 27401 it.
Pi*MW Addnss Cit},xnd Zip
Guilford WATER SAMPLE W/SP-22
C"W No.(Pita)
Sb.140tudc and Ungtivitc in dcgrms/mimstestsecnndsor decimal degn= 22.Certification:
(it aelt'tetd rareI200r@isskilltiere)
N W B,r._iann.Ew� 8/26/2021
SigmumofCtaffiodWcHCauftwos � m &e.,
6.13(itt)the well(d): f.Tperimment or zTemporar} Nor signin#06 form,t hrnrb,two that Ar wrfi fs)wrs joro z)cwn mrW in aet`+fd4mve
n4rh IM NCAC 02C.{rival►or l SA AICAC 02G;tr20Vefl Constmaim Smndmda and Atka a
7.lx this repair to An existing well: Mes or WNo cWy f thi-wonf hRs bw"pmr4W to Ae w4l v sner.
tf&fs€t a reprir.fit axr twoi weflCorutnratim htfufsgxettnn and F'Wkid r*xa(we 4die
rnw r ander#21 mwaf s:srctuxf or an the betrh af"form.. 23.Site diagram or additional well defafls:
You mag use the bard:of this page to protdde additional well site detaMs or weil
8.Number of oohs constro ted: 1 construction details. You may also attach additional pages:ifnecessaly.
For errafd)ite Infeeriwr or Awl-4,twr AWy tarts ONLY afrh die sm a Wi—Toartten,you em CDBi1LT 1 TAt IPTCTD�7DNS
tadndi~farGn
9.Total wdl depth klew land surface: 26 (f ) 24s. For All Wclirta Submit this;form Axitlrin 30 dais of completion of nr11
FormtfNpit wy&tist.rtl!'*pihs fdiJlewo 1exAmj+f,JQ2W*eMMW) cvnstmaWn to the foltemiriF
10.Static water ln,61 below top of easing; (Il,) Division of Water Resoiirtes,Information Processing Unit,
#1USIfr feed If dhoee critiu$>ust"'+" 1617 Mail Service Center,Raleigh.NC 27699460
111,Borehole dlarriet":2.251 (in,y 24b.by fokWall Wadi ONLY: ,in addition to seWing the fowl to the addrm in
24a 2bme. also satbmit a copy of;his form`` tihin 30 d*s of completion of ua
12.'1Vell cordtsrtiction i ethod;DPT eousttuctioa to t111"1o110ii*iitg; E
tke.mqw.rotsfy.cwbld dirm push eft.)
Dh'islon of
WitteailRS�ice Center,ride gr and Injection Control Program,
FOR WATER SUPPL V 1%9ELI S ONLYC10,NC 27,6"11636
13a.VIM(gpm) Method of test 2-sc.For Water Stre&&lW ction Wells:
Also submit one copy of this fonts teithui 30 ftsofcompletionof
13h.-Dis3afex on t,7u Amount: Avell constriction to the county licallth depsrtnicut of the c ounty a-herc
constructed.
k
Palm Celt-t Nonh Carolina F? ianmcnt cf1?miman rt and Nni W Resaurcxs-Uhisiau of Watsr R6sMM ReOwd Moist 2013