GW1-2021-07861_Well Construction - GW1_20211102

i
WELL CONSTRUCTION RECORD � Far leaerml Use ONLY:
r 'iltis f%`Henn beescd W sitig)c of nnrltiple wct s--.
1.Well Contractor:htformAtion:
Robert Miller rfOM 101 tirsckimlolx
NretN. oiltudm Minw A. ft.
2675
IJC Well Cotitiacterl`cniftionNrin>bcf tS.OUTER CAS FIN G- irnvHtiasitil'�ttRg"ORt,I[ Rfifa 17caE�k
FRt1M TO DiANPETEtt TTTiCKN M MAWRTAL
SAEDACCO Inc 0 fL, 5 IL 4" la. SCH-40 PVC
Cetotpcur�Nathte It..NNER" NG'Q1t 77lBIN'G" '' 1Eeh ial tldhed466
FROM TO DIJ NETER. THWKNESs MAWRIAL
2.Wt l Construction Permit*:
Mxi 011rr ilreiblr.srd1 fhWtr fix-.Cmrnrv.SMde,-tdr,ririrwe,Trl'a'dcn em::)
R, ft, iAl,
3.W'44 63 (t"i Fell us f 5(tt11 N , Al"
: . ,�_. _.. .
Witter r Sul►,Itl°well: FRONT- TO_ ptANKITER STAT 507 "'IC't;rn AmTC tA1.-
OilgTieatltit_rtl �fl unitipaliF ii1c 5 ft,. 25 ft. 4" Ire .026 SCH-40 PVC
OCbotbanw.1(Heitinoboling Sapply) OResidential Water Supply(since) ft ft t
13 Mdustiriif UlCommercial OResideotial WiterSYipply(shamd)
,FROM "Tti MATERIAL FNTKACVdKW MSRIOD t4 MIQUW
01ni tion 2 ft. 3 fL Portland pour
Nor-Water Supply Well:
Injeellon Well:
Q 4t)teifcr ltechargc itcnuetliation SAN'VR Nt IA`_R aat. tip 4s astir t n
❑Ayltrlrcr Stortgc and lrccQvM- Ms'llinitr'l3artict 4 fly 25 ft, Silica Sand 6/20
❑Atlnbfci"feel l*IStc►tmtn;ttcr tSt;uig49
ft. ft.
❑I xprternental TcImology OSabsidmec C,oleml 20;-riR11 i\Cr}1iUG7a� iliicb'fidiflfiiariii'tdliceisafiiccc�snri: ...
❑C,OotktftW(Closed Loop) ❑3iaeet :FROM= T" DfiSCRTPTIA3�eabr.Ih dnea+n.R'mckh �irbt'de.
❑Cftfitertual tit Gaon. a Mum) ®Old Lver aill Under#2.1 Remads) 0 iL 25 ft Tan Silt <—7%
4.Date Welt(s)Contpleled., 9-27-2021 WeD ID#SVE-12 u "�
Sa.Well 1.1)Catglni rr ft t\1(1. T.
7-Eleven #36069
Faci ity 1wmen Nnm FacOhy iDN(if appl.icnblc) ,
2375 Lewisville Clemmons Rd., Clemmons, NC, 27012 it.
Plgsacol AiblreS Oily-MA Zip 2t REM tiCS:'.;
Forsyth One foot bentonite seal from 3'to 4'
Cstetttty Pafi:0 Middfli-Won 14a,(MI)
5h,1,46tude and!Longitude�in tic nse minuteslsccrinds or decimal dgpws: 22.Ccrtification:
(It Ms It f`tq,°t�rte I;iU1p0919 RMMG�fi 1
W 9/28/2021
SiE®tnt`of Daft
SIIP4'Fiiian@nt or oTemporary By signing sig.;ng ma pm t hereby rer4j of the nwfi 5)was teem)ewntrtmeted iur m-confanex
i4drli 12M NCAC 02C.01(V oi,l JA Meow 03C.Os'M 11ea CexmtKictfmt SraattaWt a nd omrr a
7.LctltixareliArt6ankAsUngweth OWs fir MNq ��irt�tJiitmrrarcJland»enNtf+'1'rJGaftiatirairttrumrr,
if th(.`Jx a repair,fdf owe kpv4tn ysril corwntcrfmu beAgrr Won mut explahrthe oirreare of rite
reMiroji frriOl rema&.Y&fian dr.aa thr brwk oft is forvi. 23.Site dingrim'or additional well details:
You back of this page to pruN7de additional well site details'or tt'ell
8.Number of wells c anklrurted: 1 Consttuetiottdetoik You.rtiay also attach addltienat pag6s if necessary.
Fur,irdfi#e Jnftcrhrn or nmi-imfer iRW,r hr(fs ONLY ndrA tJli:14tANf Cd1rSilrMlJlNr )x�ll can
svhmit aue fare.,. St7BNf1TTAL 1N£TEICTIONS
9.Total*ell depth bed land surfacAn 25 (�,)' 24a.For Ali Willy, Suhntit dds':f inu within 30 days of CoMplction of Well
For rnt/f+}PIII KTff$Mtr athft)ft tf d i-erne(ea-fMok-J@2tV'straf 7@ IM) con44i icti0i to the follRsxingi
10.Static eater level below top of casing^ N/A t ) Divishlin of Witter Re'source�,fnfi►rmation.Proreesing Unit,
J/tt+arrr 1617 Malt Seniec titifer.ltalro8 ANC 27609=1617
IL Borehole distract r.10.625" (in.) 14h.1Filr In oTn Welly ONLY., addition to sending the form to tine address in
24a above..also submit a coo, 6f this fort within 30 days-of completion of aeil.
12:Well"aottstruction nittbod: 6.625" HSA Coitstntcttoirttro"Elie follolifine_
(i:e.s„Ecr>olnry.cabN.diterA pasta etc:} Dh islon of Water Resource' :y.Underground[ujeciit►n Control Prag�attt,
FOR WATER SUPPLY WELLS ONLY:' if136'Nfig Service Venter.Raleigh,XC'276"-1636
13,%Yield(gpin) Method of test* 24c.For Watcr,Supply&In•ectbon Wells:
Also submit one copy'of this filial within 30 days of eontplet.ion of
13b.DiAufb tram typc Atnaunt rve11 conshuctio l to the Counh, heakh deptir ment of the CcRuth`4Chm
constntctcd.
Feria GW-1 NoAh Camlim Dque nanE of Eminma ettt aid Nun"Reseums-Dhision of neater ltesom)25 Reeked Avmt Zol a