GW1-2021-07882_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD
For irmenml klse otvly:
Tbs Ibnn ran bc'uwd for stogie or mWtipt.nc#is-,
1.Well'ContraetorInformation:
IC IVATElt ZONtS
Robert Miller FROMT(i DlSCNitTiln
ti'ctl Goiahador N`ar»C ii', ft, f
2675 fL fG
yS,OUTER CASiNG-` or'emHi-dti%W*iAs'OR,.LTKJrRi'lfi! 'ticabkl
NC R1eli Commcroi Ccntfreet©u Nvsrticr FROM T8 VIAMF.TER T®TCKNESS MAMTAL
SAEDACCO Inc 0 fL,1 15 tL 4" tn. SCH-40 Pvc
Ceogltnf�Nanx f6: T1lER[a151NG`OR`=7lIBiI�C' 'iMi?n3M&si4a. ,
FBOAT TODtAhTFTSR.. TTiiChNF.S4 ArAi MAL,
2.Well iGonstru#ion Pcrrmit " ft. f, uc
l srplt tsdifiehrdt,(Er.Counts,Swr. )aria r,TRfg'DOn
Ct. ft, in:
3.Wefl,Usc is reel;well rise):
WaterSappli•Well: FROdT TO . atAl►t6T�k >frFl;rr'F Jr"jCKJ%W'S MINIMAL
bAgriculilr i�al M(tnicipaillmlic 15 ft. 25 M 4" in .02d SCH-46 PVC
CGanthe el(kfeatingiCooling Silly} CR.esidentiai'Water 56poly(sin le) f� fc in
❑IndustriallCornutercial ORtesidential NN"at rSupply(slmmd)
OM To ATATEREJ L HKffUCftM iiT AWFHOD&MIOUNi
❑lam doe -MOM
'6t. 11 fL Portland pour
Non-V4°nter Supply Well:
fL. M
bM22(grin ❑Ft per
1.0jection Well: - fL fL
❑Ati(uilecr Rccfiarg GldiollywV;10 ncntcdlail?ott «SAN6,IG `: 1•wGltflf
rn►,sr TO I MATT ant t{staa ar xr tArt rn o
❑AgOwFsr$tc►rtgc and>rccayeiy' GSoidniiy t3srrict 14 f>r: 25 A, Silica Sand 6/20
❑A®uefer fcst QStomm trcr Drttong
13Egserimcnhil l"ochnology ❑Snbsiitcnce Coiaml
2ti,:I>Rif. lilG+7AG7sliicb ad►Tinanat dtii efsreceaNnea
❑G:oth rttaal(Closed Loop) ❑)laser TROAT To DE9CRTf'ON 0br.hardno.M lowriktt F t*,&6
043601 tertual(Fleaitir g2oG. a Retmn} ®pdter(. aiu and&#21 Retnaft 0 tt 25 tL Tan silt
% fL _
.Date Wells)Completed; 9-29-2021 Will;ID#SVE-1R
S&Well lalcetiinn:
7-Eleven #36069
f'ssilitpl0necrNar� Faciiiyimtarappltnblcj fL fL P �Er,•;;�:t
2375 Lewisville Clemmons Rd., Clemmons, NC, 27012
1� N MI
t'1¢3icsl A.dt9�ss:Cityi',and dip :3f Ittl►fARi►&;,
Forsyth 3' foot bentonite seal from 111to 14'
t,'OiUB!` pamo tdGnlilicalion:N(i,(PIN)
sk 1-irtitirtic`and Ltingitadc in dcgrustminutcAccrinds tardeciriml degrees; 2L Ccitifkation•
orti'en iia:14,roc L•wMort is grdi9cicri)
]1° W 9/28/2021
Siget3tnc of •��,r' Oak
6.Ls(arok iltc:�rell(}: EFzrnianent or oTeniporary
11p sr'gning ihis.,{lr+m,!$stet*v errhf}•fhav thr irrfl(r)Mxtr{MitrcJ mmunretErl ut m+tsmrrlu+a8e
Wrlr'15A NCAC-02C,01(70 or 15A NCAC 01C:02M Ni fl�r+.inrrrirvl��r Sraadai&and-Awl a
1.h tltes a repgi€to an Mes or ENo acyir b�rlraF rarand h+vh Sn'rn pri�rirlGvl rr-ache�irVr{+wnrx.
lf+frts`ls.n relaair,fidl rtivr firratiiuAi rsull c�av+bvrurtii'rnu dreforr�?rlon eau✓rhpraf+r rlas nnrr,re r+jrAc
repair mmkr 671 wmarkx srrliar+M rm the back bf thhY form. 23.Site dikram or additional%441 dehuLs:
You may arse Ilk back of this page to OFOA(e additional well site details or well
tl.Num6cx oP wells c nn trttcteol: 1 construction details. You may also attach additional pages if iaecessaty:
fbr mutrkrtic l�r}ecikwr or nrNr-niarcr rbtr+plr a c71s U+�'LY ti lrl)rlie.srrntt construclkwr,S rnn can
avh+nit our h m,. SUBMI[TTAL INSTkICTION4
9.Total welI depth below land surfaces 25 {ft.) 24a. "t-All'V Well Suhrnit this.f`brm n thin 30 days of tomptetidn of,well
Formaftrld*lrirtls"Fbi�rllr��7+ti�5?Itrr :ti+tt(exemi�ts 7E?t1V7`dnf.2�?11k7! consinictionto the follonitfa:.
10.Static water level below top of caShto N/A (�� Division of water ReR4nr'tei,Inftirmation.Frotessang Unit,
tfiedietkvei babove ras1eR;am"+ m 60�Mait$ iee(`;enter.Rileighi INC 21699-M7
11,gorchglc diameter.10.625" (in,) 24b.For iniziloe NO ONLY• the addition to sending ti►e form to the address in
244 above,also Obtaft-a copy a`P this feffn within 30 days of completion Of t&t.11
12,Well conctr_fre°tion trrt bod: 6.625" BSA constmction to tine 116110ir'ing.
(i.e.sup"t._ioesq,cable.dins pask etc.)
Mislon of Water Resources,tudergtound:fnjec lon Control Trot,
FOR WATER ST3>aPLY WELLS OM.1':' 1636 Mint Sirt-ice tenter,Raleigh.Alt i7699-1436
13a.Weld(gpm) Method of trst 24c.For Water Supply&lnlecti6n Welb:
Also sublttit 0tas copy'of this f6rii'i x6thin. 30:dpysof-conipietionof
13b.Disinfeltltan t1&pc Amount: xcll ceristnrctioa to the county health department of'fhc cotin1%x4hm.
constructed..
Fonn GWA North Carolina Departnxia of Etwiromwnt and Nana"Resources-D`nisloft of R'aler Ftesou,= Rcv&d 11ttg+M 2013.