GW1-2021-07878_Well Construction - GW1_20211102

WELL CONSTRUMON RECORD Far treenwiUscONLY:
Ms rbrm can be umd rms!Aglc or mifitipk wcils
1.Well Ontrartorhilorlwallon:
A 4,IVA'Mit ZONES
John Eiseranan FROM
W01 CID19MIC6T NIft
4439A tt fr.
NC Well Contrador Cori if wfion Nunjiici 15.OUTER CASSFING Mir.iniMI-caml vt*ft)M-Alcabie)
I I TO PM ETER MATERTAL
SAEDACCO Inc 0 (L, 48 ft. 2" a, SCE-40 PVC
Coulpiny Naffw j6ANNEARCAM I NG'OR::: BINC kkiflweMil&"444611
FRO11#1 TO Duiwum unciau.ss mkTLw,*L
2.Wd I I ton5tru4ion Permit
lirx w-Hijornwi"(ke..Owmey.Stow;Marionce.ftyeckn n-)
3.wchtw(ace)zWo giso'l;
Water Supply Wal. -FR01113 To :MANUrTRVI stnTsuw ienscm4m mxrmom,
DftrLzuhiml MM11"'Idpa-VMlic 48 ft 50 (L 2" irk. '.Olb SCH-40 PVC
Mkotknwl0eMu& of,ngStpl ) Olkesidenl'Water ft. ILt y pfs
I in
01nd'ustrial/Com-filercial 01esidential Water Supply(slveed) JS,GROUT-.
FROM TO YLA
01higation 0 ft. 45 ft, Portland Trenimie
Nor-Water Supply Welt:
Injecitoa W&: iL ft,
Mquifcr Rahjr& 0drmiMvWtr RcowdialiGn -,1'9,SAN 0jGWAVELTAMIC •�j(4Vlj6hk1) -
QAqnifi,,cr Stopo ai4 ftcaa linily 130hice
ycl 47 ft, 50 ft. SAND
0Aqxfifcr"Test. 0Sjorn m'-atcr Dminl9c
dExpuimcntal To hnology 0S1dWdcnCC C034TOI
13G.'adimial(Closed Loop) '131"Meer -FRO"M TO PESCRIM03%(Mbr-1h0frdt'V",Ikult'"Xk *IN dr.)
oCsoollietival Eeatiola2oh.Lp Retum) IMOdiff jtM!ain under#21 ReMaikS) 0 ft- 50 ft, SANDY CLAY
ft. (L
4.Date,Well(s)Qnipldled: 10-7-21 WdlID#AS-19
sa.Well Location:
7-Eleven #36069
Facflk;0wLrrNuw Facuit"Wo elf applimbic) rL to.
2375 Lewisville Clenunons Rd. Clenunons, NC, 27012 ti, k
P'k-ikul AtMerss-City.and'zip 2 t.REMARKS
Forsyth Bentonite Seal 45 to 47 ft
0111* Paw milirk-won No,(14N)
$6,1*46dcanti tongitudc in de grecOminutalsecmids or decimal dcgrms: 22.Ccr-fification:
N W 10/13/2021
—
-xiPe.munent or oTemporary
,vj),h/M XCAC 02C Well CoLtuomakur Standards and Owe 4T
7.h-this a repair to an txisdag well:' OW's' or KNo copy6f(11h r'N'Wrd lino 1*ffj pm-MW ro.Aw 1MI-Rwiler,
lf;bfilv i7 rrpwr.fjly owe ktzoftw udimion"foei hVorw,06jiarde*pfafit jebentreure of dir
repair rwderP21 pmafkv.%vx-fiap or an the bfwl of this form. 23.Site di am or additional Well details:
You may,6se ilk,back of this Pao to ptoAde addi'Witt!vvvfl site details or Well
S.Nnotber of wells cotutrucled: 1 collsituction deiails. -You truw also AttachAditi'miat Paget if I Meessaty:
For in M*1ttWrkwi tv 0 rvl-liwee J*ph'ItTill ONLY-440)r1je,MM r C0175-tru&IM,yX*can
Numlif one f I orr"j. SUBAff"ALMT6CTl0N§
9.Total weR depth below land surface: 50 �jyij 14a. For All V Submit thisi fbmi-%%ithiti 30 days;of coutpletioa of Vs-Cll
to the folloning;
10.Static water level below lop of casinz (ft.) Dfligion of Water Resouke4,InformMionFrocequng Unit,
16V, rjait S ieery e(�inter 'h Ralek_ '.
11.Borebole diameter.8.2511 00 24b.For L"Wou M-Lb ONLY: In addition to sending the f6mi to lix address L in
24a above. also stkbhiit a copy of!*$feria witbin M dm,s of completibii of well
.1 2.'Wldl vomtrn-ction nitthod. 4.25" HSA collsinteflon to ille,f6l.louing.-
(i.e.sugcr.,rwayy.cable dirmI u p st,L ctc.)
Division of Water lteworccs.fU,itdergmund.tnj6dioii Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 MA Service C61tr.Rakipji,NC'17699-1436
24c�For Water Supply&Ipjedinei*Cm.
13&Yield(9inn) IMCM04 of trit
Also submit one wpy of this 6nh within,30 fts of comOletion of
13b.Dkinfixtinn type: Amount, AVC11 COM51niction to the county heldtii depentumd of the county%rix-m
Fenn GW-I Nonb Catalina ftmaxmi.of Envinmicni and NunuW Rmurces-Dhision of'Walcr kemrcm Rc%rirxd AugLdt 2013