GW1-2021-07874_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD For wt•rw Use ONLY: �
Uls Win con bc'usad rer ftle0mWiipic smells.
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1.Will Gontracttiriintbralatlan:
•14_�V1`AlFSt tSl!t0'
John Eisenman FROM tit OFS tttptti)+{
t6rI,Gtsn4r!tnrN trrte ft.
4439A
NC Well Corm idar Certifeestion Mimber 15:0[PfE1t. TN(3 'u enihl ea il:K ftl '.Oit.�,''B tliiat7lc' r . .
FH4«1 I TO lr4d1 1t, TEff{'iei�E+5 At�'rEret.�rri.
SAEDACCO Inc 0 fL, 48 fL, 2" le. SCE-40 PVC
Ccnri�pattgt�°tntr At tt, R'AVa WC, ilkitadO44601,
'FROM area DIAMMR., Tirrtttctvess ai.�rsstlr.
2.Wrttl Construction Per trit!0: tt. tr
14o4rft4%y Ura6lr wrt}/rra i ,ter.Cnvnrv.'•'t'rar:r- we Irocon ei j
fL ft, in.
3,VYcl1 Usc teht ck well as'e
Water Suppiti Well: rwtla_ tr3 :titAtiiF,fi ut_ STATT IZ •t°ttICXjvrss xrpfietivau._
[5�8a3G11iti1 al CTMnmapal/mlit 48 fr 5p ft2^ i .bib SCH-90 PVC
Ocseodiennal(Heatirio'bolipd Supply) OResidi:ential Water Supply(singe) rr. tt irr
[�ltidfestrcaUCvrtutferaial OResident=eat WaletSupply(slmd) Is.:GROUTN
eaO�r •�+� �,MTg ��,rrz.nc���rrt>_rnna��ooGvr
OtrfipAtrnn 0 ft.' 45 (L Portland Tremmie
Non-Water Supply Well:
i7tulem#tian (71�t+
IB]ectio n Well: rt, f1
C1AgirafcridCGharg; rVuridstia�terl;cnt liataon t : AN R_I,.a
4
p tuq*(t r Sior.tgt o,d jtecn sue* qS tliniitr 8t1m rn ." t A�v
a7 rx. so t`r, sArro #2
C3A reeCcrTr i [�Storurm tcrl[}r1 PW
OFxpeuinent�l To,:hnpl{a•�y CISed�sirlertcc�orl .__ ., .
��tt:.ltRtl: i�Ci?L�[5C�`��ircl�atl4i`tia�n' �hc+eii�r�mecix�si� `
❑Ggofhettnal( Ins Loop) o wtcer VROsr TO PTaSca MO;s(*bKhwrd"m tw-wrftu a AmOte
OGe'e liennal eatit oll lten9it3) ®tltllCt a'rn llfkler i l Rtritatl S) 0 tt. 50 ft., SANDY CLAY
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4.Date Well(s)Cbntpldled 10-7-21 WCU ID#As-4
ft. (r
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ft
7-Eleven #36069 { \
Fic thyt D%ver7?um- Fscnity W#of Wpi cible) f�
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2375 Lewisville Clemmons Rd., Clemmons, NC, 27012 tt fi4, Z`i -
Flgsicat a5i[r9 GiFi°_pnd2ip ,
2VAILIAt+
Forsyth Sentonite Seal 45 to 47ft
fomw pArtei 1t3Lstfettrwltlt3i5Alp,(t«ff)
Sh;I 4t tide anti t cintgiti d in(It u0ninuteg/k6nds or ticcinal ftreess 22 Cr etifiraiu►a;
{tt Ntlt'ta td,true ttitfp is g1eftl6diti)
R W
�~ 10/13/2021
5igmluit of ,w z'� bm Date
6.is f arm the welt(3): miff anent or OTemporar', �ryniit xhas.IF�e r ciu:M s zn '�r e j axmrluu�red us my n lsrnrr
re3rrt!&i NCdC-0r n"'„E,4w; i';�tY+WefloircrrrtcrJur v rearadcrraf arrsr#M�oi tr
7.Ls this a retiair to in tititit%ng well:' t:7Sre tit �i+t(i weir Af tJids raxxrFlf firth£�crn prm fircf rr;air tirrff mrwrr,
If r6 `ka mpoir,fill ow Aro4vi wdi cmrarnttv4raru drrjamVii m dimf tApfdbtrAe'trmrrtre rf rhr
reratietr er l rcrurarJLs:rcxlitxa r5r rixl tfie hrx�of Brix furui: 23.Site dI1Sj;t am'or additional well detail3:
You rifak lrse the back Of this pa 11to proAd additional tall site dulls or well
S.Number ofvwelbcomiracted: 1 �ansttuetfniidetei�. You nab'a�bbfaeliaeld±t3b�atp�t�sifta�es�rv:
Form Yat{e(rhrte r&aei. ronvrrr vew14tpply,itr?fs ONLY%*Arte moot coftsb'arAmi.,prir,em
suk+natcrxicjrrrrs?. S1J11i11i1"I"fA .118Tt AdONC
9.Total well Aeplh belowland srerfa 50 (N 24a..Ebr All Well S4bimt this'loran uilhin 3tt diets of coniplefion of ilea
For srlf rf'T*5 iddlfrrvit(ex m ph-J@Z00`mW 2@ IM) ccmSintCtiGry to then lotta-Mog;
10.static water Icr't`l below tap of casing: 00 bf* iiin of Wetter Resod W .3,Information irmcesting Unit,
if 66tet•,-Rate, hr lY 2760-161[7
i
it.ti-orebole di4meima:8,25" ( ) 2413.Fnur 11.Ik 'V6'c:Clg"ONCE': Irt addition to sendiaag the font to the address to
24a ab>n�e, also snUtnit b copy of this farm within 30 day 'of wmplelidn Of alit
12.WcltmmUvgtlr�in pietbod; 4.25" HSA ev'131metinti to the follomile.
(i.e.supt,ijAiuy,toble'1dind pusk rtc:) Division of Water Resotarres,
Viitlerground tnjeciion Control 1"rog raati,
FOR WATER SUPPLY WELLS ONLY- 1636 Mail 5erc let Ctnitr,Raleigh,NI C 27699-ib36
13a,Yiidd(LRlfun) Pric#h4d'tif tt 24c,For%eater Supo &Injection Wells:
Also smitittt tints-copy of this fotua ssythin,`30 ft s of conspeetion bf
13b.Dist fecti to type~ Arnoirirt: +sell cOrmnictidtr to the county hAlth dep ament of the cminty ahem
consiructa
Form GW-1 t!tnph Camlina Dell-n e.PCE-m inmu reju sand NaoaW Resources-Didilon of Water lt ouvm Remised Atgust2013