GW1-2021-07867_Well Construction - GW1_20211102

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WELL CONSTRUCTION.RECOMD
For Irftnmi Use ONLY: I
'iRe fv[in sdn ire u�d-Cot cmgk or rmiltiolc n+clls
1.Well GuntraetorInformation:
1411WATE1tZONU,
Robert Miller FROM Ytt DrSI-RtI"lit}
1��ClI Ct:3r_t;nEt7r IdXniC fi, ft,
2675 ft, tL
NC Well ConnaorCcnifmm:i6hNvmtira t5.0117ERC`gSiFtCr ormuFdies�iviirclls ORL1iYf:RIITa"T�cs,t+k
FROtt .TO DIAMETER, n"CK\w% 14ATERiAL
SAEDACCO Inc 0 ft, 15 fc 4" ir3. SCH-40 PVC
Co,�tp:�iry Nook 16,iN,.NER(.'i1gi do k4.14 i
'FROM TO DtAiktETER I THICKNESS I MATERIAL
2,Wet ton.0mition Pcomfit
lard#11an kahlr.wrtlywimitx ti-e Gbunrv;SNrbr ,traria r.Tilaogt rvc:} �# f4 ie
3.Fell 19se(chixl,tk-cil use l l St;RI l Pi. u a,A
«rater Supply Well: - - FRO,%l TO WANU IR RATS17. T"IMNF-SS MATRRIAL
�Agr cith trai t Ivtn7li<tipct.U�'ttblic 25 it. 4 15 % 020 scH-4o PVC
tt. ^ 1
OGeothemta (lie.�tin oliog St ly} ®Residential Water Su ft ft. in
� tyAlS'(single)
❑LndustriVI Comniemial OResiden� �fa l Witel'� '{sled) `�QGRO� nr nr ►trtrwc > rr A non& iounr
❑i[ii lion 3 ft. 11 it Portland pour
lion-Wake Supply Well:
❑Monitoran i�ttcc@tic fi , ft
Neciton Welt: (L ft
13A4nufcr9c63'rgc Odmindsou RcttrediM on :j4=:Si►N11,lGttA4'EL:
rRlif' rI NIATAREAt r7l1Pi 4t1ir.VT ti[It ti
pAquifcr Storage and R�cOFt r}' p$alinir unifici 14 ft." 25 ft, Silica Sand 6/20
❑Aggrl�r`fc$t i� @[11[{\•ni,C[l�ryEn9�
Mxperimcntal Ta--linotogy ❑Seb-ait we Con"I -
2fi.nRI1.1R7i�G'3OG'fsilirc'b�iildiiitiria`l�l�ceisif.sKcc�snra�5 -
EIG:Oilt-OW(Closed Loop) atmcer tabr.hard"t"sr,Rrrii& r d .Ne.
❑Goodiemial(Fieatii lCaoli i?Retum} 0 fL 25 f4 Tan Silt
rL' ft
4.ll'ate We11(a)gmpleied: 9-28-2021 Wdl M#SVE-8 u i
q.Y
9a.1'1'cll t i►�ativin. fL it.
7-Eleven #36069 f4 tl „Willi A
Fsroi7iilaYltvtrrNnrne Facility 1Dl<0€applaenitic)
2375 Lewisville Clemmons Rd., Clemmons, NC, 27012
P1 ikid AAdgS!�Gi*.and Zip 11 RCAIA KSt
Forsyth 3' foot bentonite seallfrom ll'to 14'
Gt�britr` tsartet tiisrittC�ntlo7Atp,iP]-111
5h.1 otitirdC Rod i orrl;atitdC in.dCg�cF/mnuttfiscconds Fir decimal ilCgiCS:
22.Certit`katatkr:
(1fwc11fic1Q,• ,L•itHpr�ds greftiei�i�t}
It W 9/28/2021
Dak
6.Is(&re,)the-we11(4): MPertnanent Or 13Temporgry Ity signing lh&. ihere,y eer 7hrar the vrll s)was i' -erwl c ntinreted ur"taxwAmcr
u'hN J M NCAC 02C.0100 or 154 keAC 02C:O:M Well Co urnit rkw Sanxrdor s caul An a
7.1N this a repair to an eA*stipg n'elli ElYes- ter Kinks ropy GF(NT rm;nf 00i began OoprirkW rn al;NMI mmer.
(rrws lr o rr p, ir;fall oar P6*itw well rcrrrrrrurviorn ior,Iorrmfk,n rw4 rvolabi Aw+twine of rAe
reMir kffder1Oh rmnnrUr.ywi6 ra orrm thr hrxt of fAiNhrnr. 23.Site diagram or additional►+'ell details:
You 1603E use ilia back'of this page to Otovide addilioml VIA site details or it-ell
8.Number 4f vi'ell9 colnstructed: 1 eonsituction defaits. You may also ailach addilionai pages if necessary.
For—110 lnlc+a'r"i or ntwi-realer s qq oy n'rlls ONLY%IrA rllr srtrtie consfruellort,yo+i rma
�nkmer ai r four, S ii1MUTA .iINCT MNS
9.Total*ell depih bekwiand surface; 25 (ly,) 24a. For All Well ii Su'bndt this",form itdthin-10 6*m of comptetiob of otit
For mid4pfeKaillsfisraflerpiksgdiff'rren)(es{ma+le d@'20ir`Haan2@IMI) Con.stnirgiontoIlk otteining;.
10.Static water level below top of casing: N/A (�) Di loon of Water Re}%Ourcts,Lnfirroigtioir Prn(essin);Unit,
Ifrrotee level b dtwve autrtg V*"+" 1617"mail Scn•iee Ccritcr,P.aIciah.VC 27G09-1617
11.Borehole diameter-10.625^ (in.) 24b.Far fnttCOQ11 Wetis ONLY: In addition to sending the form to like address in
24a ab ve. also subadt a copy of this forot within 30 days of completion of well
12,Well construction kit bod; 6.625" HSA emmictioii to ilia Nlak011g
i
(i.e.suGcr-iuii gy.cable.dind posit etc:)
Division of Water Resourc&,Underground[njecilon Control Program,
FOR WATER SUPPLY WELLS ONLY: 2636 AtA Sctvice tinier.RaleWi.NC 37b99-1436
13a,Yield(gpm) Method Of test; c,For Water uVW &[Wixtinn Wethi;
Also SU61,iit wie cop} of this faith V61hin 30 days of coinpletion of
13b.INsinfaxton hVe: Amount: c@nstrtieted. i f�aa d riment of the mintyn•1=
well constniction to the cotmty
NMI GW-t taarihCamllnzGpsrin>rnroC£nvimruueniandNan"Resomms-Di kionofWarcr-Rmm tes Rc%1scd 4t4grst-Mt13