GW1-2021-07913_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD For Inkn nl Use ONLY:
M's fb m win be used rw singlc er rr dti}k wclfs
1.W11,Contrartrorintormatlun:
4C VATER,7ONES.
Robert Miller f'nO:5i T(t 00Citlr°rt I
U'dt CarrtorAPT Nit1W ft. ft.
2675 ft f4
NC Well Corroactor Ccdifidatirirl Nruitbcs &OUTER CAS ING-I Mr"m ihIl %-cd vrd) OR[LINER t it Fcabk
FROM TO IIIAMFT6it TflfCiCMM 1114 IAL
SAEDACCO Inc 0 ft.. 5 tL 4" ;® SCE-40 PVC
CNIVwxly t,tantc is lNNE�R 'NG-'Ox TUBING `i6iraroal rkfiCdaoa
FROM TO DWNIFTER.. I TIiiCTWF,SS I AI.ATERLV
2,Wcll C,.Qnstruetion PciTnit#: R. A
liar of/mr�?irr> tr.xrN,iriinut fP:c;Counro.Sutart-tfndnmrr,In�atlgl ate:j
fL f4 ir%
3.VYdl.Usc(chock n'll us*
Water Supply Well: FROM
O,M � :IDIA�r6�'rtn Si.O'rrrrx Ir"IC cNtccir MAtIKKIW,
®Auhitzal CilvltanicipctliPnblic 25 in, '.026 SCH-40 PVC
OCaeothelnral elfin r43 �boli. ' St 1 ) OR.esidential Watcr Stt t), fr. in,
(H III Y P'A15'(sir;3le)
❑indust�l/Corimie�al �Residcnts�i''�VaEe�St( A&BRo[FT_�._:_
pply(Shared) FROM TO MATERIAL ERtPtAC�tMMTAISRIOD&miouNT
ohri' than 2 (t. 3 (L Portland pour
lion,-Water Supply well:
OMoni#cslsn AttC Osr rt
Injection Nell: tt, fu
OAgtRafcrRcGharrc 0 rouiduitaRcowdWior (MAjil4lr 63. -
rRO;Ir TO RIATRIUAL t{s,fpr ACMIVxI'Atr:'-I'I n
pAntn`s(crStOrtgc oad 1t Ct?Fc?}` 0SIliniTy Bardo" 4 UL 25 fi. Silica Sand 6/20
17A quit er'f'cszt [7 tOrrnm Itci Drain rye
❑R rimcntal Tcchngtogy 13Snbsidcncc Control
'31t l)Rtl.l 7KG=litiG'falfacb�8rfition�a't dticels if urecessen<3
t7Gcotherrrral(Closed Loin) ❑'l`racer tratoAl TO DfisCRFMO Eabr.6ardac—n x.KlnKtetr ri Am
❑cybotttelml Oeafhg2olime Retum) o0dier itmiainunderil2l Remarks) 0 R. 25 (L Tan Silt
R. rL
4.Date Well(s)Completed; 9-27-2021 Wg jD#SVE-7
ft. fr. ,n.;•
5a,WellLineation: p t-mil
rc. tt,
7-Eleven #36069 ft. fl
Factlityi,owtrcrNanic Fscaby TDk(iEappiicablc)
2375 Lewisville Clemmons Rd., Clemmons, NC, 27012 ft, ft, ,,rrtt:':t •
_;,,�Ar�
t't¢sacnl Addss City.and Zip Sri"RER1A1tf:&q
Forsyth One foot bentonite seal from
C:7aat_i, 3}artri tAsr4ftctnifaa Ne,(PZl1
5h.1,40tirdc aril i rinoude Ii degmcr4mirnatcslwcnntls nr decimtll tic r s: 22.Certifkaturn:
O(Vs 11 Oita,CAIC Moo Mlafiidt3erri)
)r` W 9/28/2021
5ign3mrrof ii ^-- Date
6.Is(argil thre.well(s): MPermanettt or oTemporary By-signing Ab fiffm 1 herrhy re ` rhru Me,rrfl s)nYts(were)cwng-rnrered ie,am+>z Owner
loW 15A NCAC 02C.6I M or:l SA NCAC-M.0200'We11 Consf rfn6i w SraWar*and tlaaii er
7:h-"a repair toankAsthigi'elli Mes or MNn r<rli��frhirrrroir{hrrslarnrprzrlr&vtrnat.�r+tt�+roncr.
(f+trtF'#c ra rervmtr,.fltl�rrar�moiwv r+tastl conar+nrcr(�rw drrfoxnarrlfvn apart r.vFata$#rAe'trarure ref rbr,
repair affdert21 rnnrtrkr.vertrmr rsr ae the hmek of thivformt. 23.Site di4ratn or additional well detait3:
You may itsIe Elie bacb'of this paje.tb proAde additional well site details,or Nell
8.Number of wells constructed: 1 constructioadetails. You may also attach addifi6hai pages if ne+cessaryl
For mutNtate lnfr+a'rlaar or moii-ivitier rJtlWy,wrI4 ONLY a,'lrb thr artrrrr ca#*;reAmr,'wM can
awhmdr ene form. -9UB M ITTAd;1NSTiWIMNS
9.Total well depth below land surfac.:. 25 (ft.) 24a. For Alt Will Subndt this forrn uithirt 30 days of completion,of`tell
For atraffatpin ivells'l tsr nil ffePiki tr'dIff-i:re•nt(e.rr mAok-3@209'amf 2@[Wi Construction td the tblkminr,,.
10.Statie water level below ttrp of rasing N/A (�,) Division of N?ater ReiinurttA,Inrrrmatiau Proc"Ung[mitt
If ti,nire km Is above tadag.&M +' 1617 A1aU yen iee Center,kaleo NC 2 7699-MV
11,Rnrebole diameter 10.625" (in.) 24b.Fnr inirefinrn Wells ONLY: :In addition to sending the fora to lite addrm in
24aabavee. also submit-acopy of this form within 30 do)-s of eonipletion of tall
12,Well ourttnetion method, 6.625" HSA construction to lice fAiiWing_
(i.e.upi.rotary;cable died push ctc.)
Division of Water Resourc0,Underground Injection Control Progtarir,
FOR WATER SUPPLY WELLS ONLY.• i636 A"q Service Center.Raleigli.Ale 276994436
134L'wild(gpni) A'Iedlad of test: 24r For W,rtc'rSnpply&lWcgion Wclb;_
Also sabrhit one copy'of this form icrthin 30 days of cona(tletion.of
13b.Didnfee ian hT,L Amount wc11 Construction to the county lreahlt departruent of the County where
constractcd.
Fenn MV-t Nodb Carolina Depwtnrni of£nvimimretu and Alma Resoumes-Division of Water Remtrtc5 RcOsed.At t 2013