GW1-2021-07873_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD Par 1w.nwl Use OTtL:I
M's form ciin be used for ftle ar midtift weds
1.Well Contractorlttfartuttion:
MAVATER ZONES'
John Eisenman PROM * M$CR1P'r MN
WalC.10rostdrrtNam
4439A
NC Well ContworCcniWationNumber 15.OtfT R., ASIl+1Cr` it'r'erutti-ea!?Ed"-tl '(?RL&M:if" Ficabk
FROM TO PiwmrTrm TFIrC'FiNFIRSr MATERTAL
SAEDACCO Inc 0 h., 48 tL 2" Vie. SCH-40 PVC
Con t1l•htanrc &.11N,�R11AM 'i]It:771BJ1t1Cw e�tiihcYin'ai iri if 111t'
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FROM TO DIMTETER, TH1CKWESS MATERIAL
2.Well Construction Per rriit#; rr. rk mr
fisrirll.r,�y,fiirrblr.xrillieinaitr fdui �nrrriry;Sruar.;.t'ariarter,lnf�b'gl crr.:)
3.W41 llsc(chtxlc b cll use}
Water Supply Well: --- — --- FROM, TO- 01AA,1F;XR 4t)T$Ia. TnICKINISa I MATRRIAI,
15t1gtichthural tSIJlntiitypaL ttblic 48 fk 50 ft.- 2" in. OlU SCH-40 PVC
®Geothcnwl fFlcattng/Cooling Sttpplyl ®R.'esidcnnal Water Suppl�'(single) ft. ( )n
ReinC� � �STppb (shared) HAO 40 MA TERM
°:. TMP1ACT�M�M. t1-j;
i0T1 Z;MOIJNT❑odustm�llCo�%croal 'is.—GROUT:
❑lrie"xtion 0 R. 45 tL Portland Trennie
Ikon:Vlrater Supply Well:,
❑NtOiritnrn 171tecu�t �, fi.
Injection Well: rk rt,
0Aguifen9C6arg, ❑Chou wwwr Acniediat on 19._SANb 1 A> .�i. 'll�cttbte
rltl�iQ / _ - RIA9`F rAt. ESift•3,A1'T;iir\T Mr:Y'FIQn
❑tl(ltlafCr..�`torlgc aid it��lYel�' ❑$oldpin'Sar icf 47 (f. 50 (k SAND #2
❑Aqui(er Test ❑$tornmater[)mine
rt. tt.
❑Expcetimcnhl Tahnology ❑ ubsidtirc Cotnmi
°30.1►R11.�.1i1Cr'1AG'7nilsicb a'd/filiane"t slicelsir i�cccssnrv'l
t7l ewfllenual'(Clt Loop) ❑1 meet "My TO DMCRiVnty ealvr.hprd 1(,i%'ii kaer• .. vi afire ere.
❑Gwtllenual(1leatit f aol Renlrttl 1@011wr W aitt under#21 Remaiksl 0 (t. 50 (L SANDY CLAY
R. rL
4.Date WA(s)Compltied- 10-7-21 WdlijD#AS-7
8a.11ell Larcatuio f. tt ''-
7-Eleven #36069 tL tt
F'seilit oOR—tics-M lie Faeilily tD0(i(aa llisub7sl `,
2375 Lewisville Cleminons Rd., Cletmaons, NC, 27012
SMAI,4dggss.Ci _. J-
i't4 � q..undZip -.2i:1tt�MAltt;S;, -
Forsyth Bentonite Seal 45 to 47ft
Cdaulty f p (t t49 t7atiC Ilikn Pfd,(t}fN,l
Sb.Latitude and Longitudc in ticgr ceFlmintatcsls Grinds n-rilwimal dcgr ecs; 22.Ccrfification:
tlfinelt!'rzld;.*rig Lit ong15gtdltcicni}
Iti ��r 10/13/2021
6.Is fatal Itre»ell(s): EPLITManefit 0r ❑Temporary�dgniiia rhri fuv;r ? "!d .. r:a i t 4wwInreled Lr.rrcrarr/rrare
14'iPh I.Sr1 NCAG>)?C x=�'Y�'�E 4.:�z�t':D2(•Y7 N'i•.tl•G°n.�tnrr�tvr Srarraturda and dune n
7.L-this a repair to in itidisting w'ellf Mes or R'i No c<�rrs�thA4 mrrrni h�Ise err trrxrrir&rt r�il4r a,rll rnulfr.
j(rfrfa'la:a rela�tr.flll ovi trroKw tuelf�lv�nrcrtmrl�rf`omatrdar mare rcptab�else n,rrare njnc�
repair&Ader t,l mnaif s:rerrian ijr"an the bark of rhrshrat. 23.Site diagram or additional well details:
You may u e l e ba&of this page to proOde.addil octal well site details or belt
8.Number of wells oonstrttrted: 1 construction defvils. Ydu may alsn ailach addiGoniai pages if t essai fy�
For mauldf4e 1*erhui or son-hurter upph•wrfls ONEV Wth the armor cnnatarri'lh ir,you era
NuNnit one Jr m% CUBMnTAL,[NSTjjV.
'PIONS
9.Total well dep1h belowland surrrace: 50 {n,} 24a. For All Wigllk Suhndt tl»s:form Avilhhi 30(lays of completion of%V11
For imAitleivearlinofteepshstf�oreouoxoyo k- aouf.l@dim! con5him0ofitotlufoltaning;
10.Statle water level below"of casing: (ly,} b11'61ion of Water Rekour+iei,tnforn»ttibn Processing Unit,
Iftmier levet is above rastag, "+ 1G17 tliit�*;en iec Center.li tice#h.NC 274
99-1617
11,Borebotc diameter:8.25" (iai 24h.Fnr lu+chit We71s ONLY: In addition to sending the fort to the address in
24a abodes also subunit a.copy, of this forth n itbin 36 days of completion of iceJl
12.Well ron.qt1'nction rttt hod; 4.25" HSA 1'011S rcti0h to, f011MVittg°
(i.e.singer.nxily.'cnbte.diird pusk ete.)
D1v151on of Rater Resources.Underground InJecilOn Control PragMm,
1636 MA Ser►ice Center,Rafe NC 27699-tb36
FOR WATE•RSGPPI:Y WELLS ONLY- � igi1
13a,Vidd(gpm) Method of test; 24c.For Water Suppi♦&inlcclw)n Wetlt:
Also submit one cop} of this focal within.30 days of completion of
13b.aisinrix't nn type. Amount: well constntcttoit to the crnmty iwahh depadmcnt or the counily•rh=
consmicted.
Fern GIN-1 Noah Camlfna[kgmuiien of Emirwiniclu and NnwM Rc ou ices Dh klon of 1Valcr ResouYce5 Revised AtCust V?I I