HomeMy WebLinkAboutGW1-2021-07865_Well Construction - GW1_20211102 i
WELL CONSTRUMON RECORD For lntcnwi Use ONLY:
nisronncnnbeugDd1brsirg (Wmultifcncns
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1.Wd1 Gontrartorinioraiation:
14.AVATER ZONES „
Robert Miller FRtYnf TO DrU-NiIp 511
NW01Coi (ARtN5ms
2675 R« t1
NC Wc11 Corift6or CctlifwAtion Nrinaticr 15.Ut1TER C 1St31G hY'iniiFti tsrsEil r�rn O LIKM 01 n T1caE� .
FROM TO DIMNIF,TER TFHC.KiVFSS 1•TAT1Z M.
SAEDACCO Inc 0 ft.. 15 tL 4" io. SCH-40 PVC
Cen ui�N�n�r '16;:INNIr�t Ci1SING OR 7'UB1�G t«siilkryiftttkrscif-lofi
PROM 'TO DIAIMTER. TMCA'NESS MATERLAL
2.W4 l Cunstrtletinn PciTnit W.
lrsr Ofiwpyrllra bfiv ivd1itrm in fix Co rarv.Mwe,.11hriarwe,fria:604 ens.)
rt, fL
3«Weil.Use,obcdc#w'clipsc) ]7.SCItT1fd .' W.
- - - - SLOTSIM "lCKNr tANTWITF11t SS 7MATRia1AL
Water Btrpplr°Well- FwOM TO_
CIAg EGUltk1Fal OMM'idpaVPubiiC 15 ft=' 25 tt» 4" in• 026 SCH-4 PVC
045 othertrai(Heado Cooli�Supply) OResidental W ter Supp5'(single) tt: fL in.
0Industria-VOinmercial OResidentiial Water'Stippb? (shred) _ . €
FROM TO MATERM _ t?1lLPIAC�T Al MOD&MOUNT
Olmoation 3 fL 11 tL Portland pour
Nor-Water Sopplf Well:
❑Monitcrrin ❑lteco�c D. fL
TR]eci o t Welt:
ClAqukkrltccharg CaGmuridvootcrRcinediation 19:;Sit;N6lGttA\!Ti= A ,,t1 t i«1�' r. _.
JROM TO
. 1AT1;kl1AL, -. t;r+it'1,.a VAIrl YI<ir:'rN�if.
17Ati1tifcr$14ragC snd Rcoov�cj gSalinity 19ariicr" ]4 fL 25 tt, Silica Sand 6/20
l7Agrirfe'rTcst ❑ f@rnrwwstCTbiiiwt p
rt: tt.
❑Ezperimcntil Technology ❑$Asidcncc Control
�o�nnn.�at�c�l�ac:(�itsi:n�a�nuai�r,T.$t�t3 tr �s,tr,
�G.vibentutl(Closed Loop) ❑TmctK "O"W" TO DUCRIFFTON ctmbr.11atrdtl0"irJtt'hocu r .' d A?4j*:
❑Goothenwl(Reati aCw Rettim) 00dier#-. uin Under#21 Remarks) 0 fL 25' fL Tan silt
k fL
4.Date WeV(s)Completed: 9-28-2021 Wel1jD#SVE-4
(L tL
5a.Welt 1.rtcsteiln; fL
v
7-Eleven #36069 ft, 0.
Factliil.+OwvncrName Faailih-I'M df applWMea
2375 Lewisville Clemmons Rd., Clemmons, NC, 27012 fi
Pl�%KulAdtmiati•_MAbp 2i:ttll►tAYtt:S.
Forsyth 3' foot bentonite seal from 11'to 14'
Ctirint� Ntw watiriealion No,(PIN)
5b,1 iatiinde and(Longitude in do ttlrrtimatcelsccrinds or decimal degrecs: 22.Cc 1Wwation:
tlf,�it t�ra,+�r�:t;,lrtortg as git�c�ni)
9/28/2021
1c413InP o�� -
F� Date6.TS(RtY'S the Dell($): EPC`xTilatlent 4r OTemporary Hy signing thiu,te m,1 herehw•ere*-Mw w iiwfi xi ims(nwm1,:ymrrnmred in a-tnvndm ee
a•OV RM NCAC 02C.0](W or-15A NCr1C 02G.0200 MU Cansoyiunleur Srtrndurds trout rlxn a
7.Ls"a repair to an,exiNking is-ell; EI1'6 Or M No tVr bf(Uf nyor•X hear Nmj pip4d,t ri,Ow iirtr owner,
(ftlrfF 1r-rr re¢ailr,fill O"r lFr Olm well etwumrt i n br/o wai m tind j-.pfoin the owrore of nce
rr�wir render 021.rernrtn4s.rre-ritm Or on the hrxt of rhrr fnrpi. 23.Site di4ram or additional well detafts:
You tllH}'.use ilk back of this page tO,provide additiodal well site details or%%vll
S.11 umber of wells eonstruLled: 1 eonstmetion details �'imu t�iaE'also anach add,tiotlal pwlges if t►ecess ty.
f"or muf llpfe I*erdrui ar owl-11"ater s*pJr-wr11s ONLY with thr.snntr atrn *uOAtwt'yAft am
Autwift one kyn. C1111'NiTTA .INSItICTIONS
9.Total wdI depot below land surfam 25 ( ;} 24a. For Ali W'eilst Sutindi ihis:£on5f within 10 days of completion of well
forrnehrrpXRi eflstrstn(latrlul+sffdf[Fer.+�r(ertm +fr ate?f `?ruiT�e`!M'E con5tnictibnto the f thming:
10.Statie fetter ler'el belosil,k)p of Casi"W NIA (10 Divigian of Water RCRouroes,lafwrrtitutinn Pr>9cesMng Unit,
1f tiindrr lem 1s ab--iue rwIng,oN"+" i617 Mint Sen•iee CLnter,R111eighi NC 2U90 617
11.Borehole dismetcr:10.625^ 010 24b.li'nr InieeNnri Wetly ONLY: In addition to sending the fomi to the address in
246 above. also submit a cape' of this fotrti n ithia ?0 duys of canipletion of fth
12.Well nowAm-c6on method: 6.625" BSA consiniction to the fal.lowi*ifg_
(i.e.sagerr ruery.enble.diw pusts.ctc.)
DKIsion of Water Rerwurea.Underground Tojection Contmi Progrtun,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Scn'iee C eater.Raleigh.NC21819-11636
13a Yield(gpm} Method of test 24c.For Water Supply&(nleetk)n Wetb:
Also sultntit One copy of this form lsrthiw30 daysofcoinoletionof
13b.Disinfcti+ln hpc: Amount: well contraction to the eovaty Health depsemart of the eonnty when
constrncted.
Fenn GW-t Naab Camlbu Dpawb rot or Em imnincnf and Uarird Resoumees-Division of W91crRmourms RcOsed Augl9t 201.1