GW1-2021-07875_Well Construction - GW1_20211102

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WELL CONSIRECTION RECORD far Inwriml Use ONLY:
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1.Well Contractor2ltiarmation:
John Eisenman rROfit ltCf Dr ('Rtpittr)�t
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FROM TO PUMETER; THICKMOks I MATERIAL,
SAEDACCO Inc 0 rL, 48 it,. 2" i SCH-40 PVC
catIVI.-My NOOK IAmNGm(,I,I IKG be IM041 6- ' : ' a
F&QAf O DLVMTIRR I THIECKNES$ MAMMAL
2.Witt,6nitmition hirtnit#: rt. rt. b►
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3,Well us (thaac veil asap t t"!tf 1E N 3 -3- m�
Witter SupplyWdl: FROM, To I AIANIFT96t_ 4TMSr7y. I 't"rc�cNr$j�� VINr iAt,
DAgm cittitt:til Otifinaiic pmitl�itblic 48 ft. 50 tr 2^ is OlU SCH-40 PVC'
Meothetnmt tl ,emin .0068 Ripply) 0Resitlrotial W�tet Su ft: ft it*
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-twn 0 ft. 45 rL Portland Tremmie
Nan Vilater Sop pty Will:
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47 ft 50 rt, SAND #2
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4.Date Weli(s)Completed: 10-7-21 d1ID#AS-3
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7-Eleven #36069
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FacitilAa evriGr Nary Facrlhy JD#(ifapplxrib1c) tl
2375 Lewisville Clemmons Rd., Clemmons NC, 27012
P9g•srxaf:Ai�ir�ss.Cit#•.and Zip �^.�"r k�`;i's's t .«a.
Forsyth Bentonite Seal 45 to 47ft
5h,I- itaioe an#Lcinkitttrdc in 4CMW-4rniPuii0kt0tds or decimal€tcgr` sc 21 Cci fifecaa�ar.
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xaYii'i�t NGAG d2C Y 4 ,WC"0 t 0 Well r-bimrrN'r Ot Standards a'rti'Awl it
7.Is this 8 rl listit fir art txistin;ll elli ❑Ves' ;or ENar r i iayFtliav rrri7rri tit v£rrrsrt +m ir&vf trial r rrrif r vnrr,
(fWs'h'a m aair;fill umt,trrd" #ra�3t emumw to h ,rmawr'&u arad rx0fo at theworrrre nfrA
a repair Oaderi011 rem &v 23.Site d1agrarnor additional well details,
YcHj:n ab,first:thie;baclt of this paje tb lsret.-Ide additional well site details or tv It
S.Numb&of wells comstitucted: 1 vonstmetimfdetails. Yntmayalsoettachadditichal pages ifr es"sa'#"'
For mtr►pte 1"Je'rk-m or st�utelh ONLY*Irh'rhr mr;or cnar*"Mmr,yeti ren
awfrmrit rror farm: fiE1B14i1'1"1'AL fmsTEwhok
9.Total well depth below landaufa 50 (ft,) 24a. For All Wells: Sir6rttit dira f'vmi i=ithia 3n days of co4tetiot)of welt
Fpr rrtOfipfe k,effs?Ur 47#410pift if Wrens l=,matyrd+ ?U1A errmf.Z id t consthiction to the folki sing;.
10.Static water'le►Tl below mp►of casing_ (Pt.) DivWon of VWater Reiati rtes,Iitfimirtatibn ntessipg Unit,,
tf rearm level Al rboue&AIiagt�m"+" 16 t4i`s .Scniec i Mtcr,Raleigh;NC 2VOJ' 1G17
It,BonNde t 1larac gs:8.25 r' '(tnJ 24h.Ed {flan A tIs;ONLV In addition to sending the f0tm to ttpe add rm in
244above. also stbmit`a copy of this tutor within A dim'of completion sill util
!2,Rrcii 4con rnetion ri bod, 4.25 BSA eot:stnidiou to flee fo1lov og—
(i.e.aita:rataF}'.:enblr`airec#gnstL ctc)
Division of Witter Resource: Underground Injeciicrn C'ontwil Proprain,
FOR WATER SUPPLY WELLS OtNLY.' I636]Sail St tvice 661er.Raleigh,M[7-276"4636
t3a Yl d(gpim) #r1e#h0d of tc st 2.4c.For Watsi riuptil l [nimtw)n IWellae`
Also i;Ubtnit one ),of this foitn within,30 fts of,conipletion:of
13b.Dishirbot on t►yii Amount: ivc11 constructmn to ttrc counly 161th dcparmacm of the cmully:ir;lecc
e�nstn�ctixl.
Farm GW4 North Camlina t arrrme-mr.of Eetvimmunetu and Nan"Resources-Division of glrate'rResouram Revised Augur Wl I