__20220311 (30)

WELL CONSTRUCTION RECORD For lr1nwl Use ONLY:
This form can tensed for single or nnmiple wells
1.Well Contractor Information:
W..WATER 2ONC t
John Eisenman FROM TO DKSCRIPrUO
Well Citiar:tgorNnit1C
ft. ft.
ft. ft. j
4439A r
NC Well Contnacior Ccniftcation Number ,15.OUTER CASING.for.Jmuhikriseil sells OR LINER if it ticabk' -
FROM TO DIAMETER THICK1sESS MATERIAL
SAEDACCO Inc 0 ft. 15 ft. 2" io. SCH-40 PVC
Company N moo l6:INNER CASING OR TUBING jfi ottierma►tiuied4orf "* .`
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
list oll olrydir-ahlr welt pe mite(i.e.County.State.-Variance,,hyad01 n e 1 -- - -- --- - -
3.Well Use(cheek well use): Y7::S[.'Ri lJst
Water Supply Well: t w,v
15 ft. 20
0Agricultural °Municipal/Public ft. 2" in. .010 SCH-40 4 PVC
OGeothemstl(Heating/Cooling Supply) OResidential Water Supply(single) 111112111111111=1121 9
OindustriaUContniercial f1Residential Water Supply(stelmdl may OUT To >IATERtAI. owl 7/.ta00`,,,s1,4r lr) r! riirlaa
❑lmpation 0 ft. 7 ft. Portland I Pour
Non-Water Supply Well:
D. ft.
eljMonitoring ORecovcty
injection Well: IIIIIGIIIIIIIGIIIIIIIIMUIIIIIIIIIIIIIIIIIIIIIIII
D Aquifer Recharge OGroundwater Remediation 19.SAND/GI1AVELPACK if I dieahk
FROM TO stATr:RI St, ESIPI,.\CrhtENT METHOD
O Aquifer Storage and Recovery ❑Salinity Ranier 13 ft. 20 ft. FILTER SAND #2
❑Aquifer Test DStommater Drainage
ft. ft.
❑E perimental Technology OSubsidence Control
20 DRILLING LOG.(attach additional sheer iftieecisarsi
IDGeothemtal(Closed Loop) ❑Tracer FROM 'TO DFSCRtPT1OR solar hardnr ,w iVruck is .II.(v{•.eit.1
DG otitet >al(Reating'Cooling Return) ❑Other(explain under 821 Remarks) o ft. 2 ft. Silty clay
2 ft. 20 ft. Sandy clay
4.Date Weli(s)Con►pleted: 1/24/22 Well lD#MK-7
ft. H. •
Sa.Well Lueatirtn: ft. ft.
Faircloth Machine Shop ft. ft. MAR 1 # 12?
Faeility'Owyttcr Name Facility 11)k(if appli;.ihlc)
ft. n.
2355 Farrington Point Drive SE, Winston-Salem, NC,
27107 Pin skill Address.City.and Zip 2t:R1LDIARKS`'�
Forsyth Six foot bentonite seal from 7-13'
County Panel Itkrdi1icationNo.(PiN)
5h.Latitude and t.ongitu(le in degrees/mimics/seconds or decimal degrees: 22.Certification:
first ell field,one lotions it:shtlici id)
N --,��.! 2/18/2022
Sipsuture of r„- :1 v xia -- Date
6.Is(are)the well(s): 3BPermanent or ❑Temporary fue >/ /a 'sue ",
fi.rignit g Iht3 fi: o. r. _ .n. n.•.,roil,'e,.-t,vnrmteterl in ru'eor-donee
Oh 1 SA NCAC 02C ' `f r G ,:: It,0240 Well Construe/km Sroodordc tnid shirt o
7.Ls this a repair tit an existing well: DYcs or MN(' eery of rills rertrol has been ptitrad'd to tSr styli owner.
if this ii a Mx*,fill rust k»oi,vI will et-WS:n(01On lttforawriion tool esl tole the;wow of rite
rrpairtserder P2l remarks arrsion m on the hark ofthis-farm. 23.Site diagram or additional wetl.details:
You may use the.back of this page to provide additional well site details or well
8.Number of wells ctinstructed: 1 construction details. You may also attach additional pages if necessary.
For mnlriple hire e4on or swm.rart•r supply wells ONI.)'with the same construction.,voa son
subtnir saw form. SUIIMITTAI.INSTLICTIOJ'iS
9.Total well depth below land surfaee: 20 ar.) 24a. ltnr All Wells: Submit this form within 30 days of completion of well
For<muhtple wells list sill depths ijdi,(tereni lexmnpre•30209.and 2@'WTI constniction to the fottonins•.
10.Static water level below top of rasing: 12 (ft.) Division of Water Resources,Information Processing Unit,
If water trial is above easing,arse•'+" 1617 Mail Service Center,Raleigh.NC 27699-1617
I I.Borehole diameter 10.5" (fin,) 24b.For Inkcitop Wells ONLY: In addition to sending the form to the address in
24a above. also submit a copy of this font within 30 days of completion of well
12.Well construction method: HSA construction to the following:
(i.e.aagcr.rotary.cable.direct posh.ctc.l
Division of Water Resou secs,Underground;Injection Control Program,
FOR R WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699-1636
24c.For Water Supply&injection Wells:
13a.Yield(gpm) Method of tit Also submit one copy of this form within 30 days of completion of
13b.Disinfection h le Amount: well construction to the county health department of the county where
t .
constructed. i
Form OW-I Notih Carolina tkpaf nsatt of Etmironmctu road Natural Resources-Dos itiion of Water Ri_otrtes Revised August 201