GW1-2021-07883_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD Fur rf�rruflu�cz�i v: �
Th6 form coin be used fo thiFle of midtipk wells
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1.Wdl.Centractoir Information:
It VA-M t MNTS,
John Eisenman FROM Tt! bFACRIP'rtu)\
16W1 CorAm0wr Minfe ft.. A,
9939A
rt. rt.
NC Well CommdorCeriifttition-Nnmb 11 OUTER GASHNG(r2KeivHkeAkd**M0ORLjM. . 'd'if 1i&bk).
t R0\! TO I DIAMETER I TH1Ch1VFg5 I MA I MAL.
SAEDACCO Inc 0 fL, 48 ft, 2" ;s. SCH-40 PVC
CafiTffrfy M.411re 16.tnnlg9t:iC+1ri1�Ic oR`TtTe1Nc' er�ih &Wd4hiil
FROM TO 1 DIAM TER. I 1MCK"S3 I MATERIAL
2.Wilt"Construttinn Pc snit I► rt, 6L
ma oil dr,rwrw Ir u�tll frrnmi�'[P� Cerrnru;SAB�r,-1Fsrinmgr<li)s8lycq etrj rt in
3.Wdl.Llsc(chccic'`vcll iu5e) rt
Water Supply Will: 48,rrft. TO VAn f,,tR r S211 0 067j' .;CH-4,t) S, pvCM W.;
ClAgrkultitrai 01musticipal1mlii
043100111110M.1(lieMingCbolingSupply} bResidential'W9ter5itpph'.{si:rl tel ft' ft.
©IndustrialfC.ommemial 01tesidendal`1VaMr,Supp4'(slmmd) &GROU
FROM TO MATEML nTPLA MFiVT AWMOD&J010UNT
❑Irrt tr4n 0 ft. 45 fL Portland Tremmie
Non Water•Supply'Well: rt
❑1vlOni#nrinR pltccO;r ,
Ii1Jecllon Well:, rt♦ rt
0AgncfcrRcchargp 13dimirdtt�fterAcincdiiit_on I IS �C:kAti 'Ift 3.M tiL' • " -
Fpt)�t IAY4i f41 �RfIzlAfi�t aii rittin
❑Atipifcr.StOtu9c? Roca rcr}° f�Salini y flariicr 47 ft. 50 ft. SAND: #2
❑Aquifer`rc51 Cl tomurtirtcrlli�iri,v c rt. ft.
OEglcrimcn1ilT-mtmology ❑S65idCnccCondm1 -
24-DRJi,4,l'G�I OG'6d aeh:riditifiui►iatiedslrr,ecc�sai ... . -
❑G3otherniril(Closed Loop) ❑ acr vnoa# To or�sCRrPTrON ca»r.rtardncetfli'n�c&ry >f
OG;odtemiai(Fteatit 2-O a Mum) 00ther(, —Main under#21 Reciafks) 0 ft. 50 ft, SANDY CLAY
fL ft.
4.Date V elf(s)(7 n6Pietedl: 10-7-21 WAI:ID#AS-23 -
55L Nrtil G)Cativmb ft. (r.
7-Eleven #36069 ri A ���
1asililp iocrNnma Fssiliil TDOtieappitnble) fi, rt, ,
2375 Lewisville Clemmons Rd., Clemmons, NC, 27012 ft. ft, 'VV,
PtrySiml Aldus.City.and Zip 21 KEMARKS' :
Forsyth Bentonite Seal 45 to 47ft
Coiffw Pafeet IACrfiiPrt rf Can Nrt,f P73ti}
56,i Attitude And"ni itudc in.df grerrilm nutcslscc6nd5 or'ttrcimul OCOM: 22.Crtliricntion-
fitwell:treld,ofrc c>iJlpfas l5 5+atlle3�ri1) '
Y W 10/13/2021
Sfgf>3 o-of <7rIL✓y 1 l)aft-
6.is(ariicl the well(s): mPermmuent or 01fernporar}` BY ersnar hst,fw ram"/t ' ,rf r `'' ; i. rrrncrerl nr- turilar,f�
�drh'16ANCACO2C xw-�r '.:CW.7 -;k 4ZM-We11ComgrrotrimiStandor&saru'rianra
7.Lc this a repair to an itk4l ng well 01'es' or M Nu ropr_r c± d�as mrrvn lirec bcma pftn J4rd m ribs nriJ rnvhrr,
tf+bfs`trrrr+~,t�stir.�dPo�urk�aainuiweJlecn�amtnwxr�'err,�rllrvrrmaRrdploiaca7ierfmrareofrJfr.
repair aader d21 remarU, serfnnn bran late brml af'fhis farm. 23.Site diAgr'am or additional well detab.,
Ycm may-Use the bac''uf this pagd to pmlde addiliolml%Av l site details or ivetl
S.Number of welts constrocted: 1 eonMettoii details. You my also attach addt ioual pag,es if uiCessan^:
For mufdrdetnjeerdr+n.urm� -t«ravafr plraeftsUrt'IY%Jellrhr anntrc#IrSIb ctV)f'-y5"cem
subrnnfeneform,. SUBMI[TTAL.ihST 'PIONS'
9.Total well dePili bettrw lan.iS Surrg= 50 24iL Fair-All Wills- Subinit this,,ffumi ttithiri 30 flays+s of tximpfeti6o of►itll
For mWfipffiwvfklhtr 3@200'aW2@fW cvn5616cti9ntpthCf0llMing;.
10.Static:water level Below top"of casing: {It) Dh isiod of Water Re34tirt66 tnPorrmation Prootrtmug Unit,
tf itw'Vt lefts b rrdrrrur edfrig,ON,"+" m l7 mmiil si nmiev 66n1}er,RidriighyK 276"4417
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11,BOrehnlc tlismettr 8.25" (in.) 24b.&I in jMfl n ONLY: In addition to sending the form.to Ilse address in
24a above. also submit a copy of ithis fora!within 30 days of c6impletidn of tcttl
13.Well constmet oni rrteihod; 4.25" HSA c aiistniCNo(i tntlie folloi�it
(i.e.strpr.rotor)•,ca61e.[limd teusli etc.)
Division of Wateritesources,iIIiidergeonnd Injeciion ControllFrograni,
1ti36 hart@ Seri it a Center:Rale" i,N
FOR WATER SUp PLY WELLS ONLY:' et+J C 27ti99-1636
13a."Yidd(glum) Mctiiad-of test: 14c.For W.ttms'Upply ek Inlectio C Wells:
Also sitnhit otie cripy of this firm c'tbin:30,daysof'contpletionuf
13b.Disinfi,►tivin trfiC: Amount: ncll construction to the cmmty hcshh dcpartntnt of fife Conuntg lrkm
constnlcted.
tam,G14`-1 North Camlins Upftnwm of Emirmucru and Nan"Resources-Dh rbn of Almer R�Sat Rc%,&iJ AuguS!2013