__20220311 (31)

WE ILL CONSTRUCTION RECORD �t
C'1 For totem!Use ONLY:
This form can termed for single or multipk sir lls'
1.Well Contractor information:
44.W ATER ZONES
John Eisenman FROM TO I DESCRIPTION
Well Cord on:or Name ft. ft.
ft. ft.
4439A
NC 1Vcll Contractor Cen Meat ion Number ,15.OUTER CASING(for miihi-ea—red-Wins)OR ANER(H.i►i► lieabk)'`
FROM 1 TO DIAMETER, ThICK,N'ESS MATERIAL
SAEDACCO Inc 0 ft. I 15 ft. 2" in. SCH-40 PVC
Cornflour r Name ,`"16.INNER CASING OR 1_1)11 NG eoihcrmat tkitcd-tour,);
FROM TO DIAMETER THICkNFSS MATERIAL
2.Wc11 Construction Permit#: ft. ft. tn.
Jan rill ojyilie-ubfr writ prixrritt(i<r.County.State.Varian re,Infection re:) ft. ft. in.
3.Well chic(rhCVlt cell ass): ';17.-SCREEN ._"- i
Water Supply Well: FROM TO DIAMETER SIM SIRE TJIICKrs,s t MAtemxt.
°Agricultural OMunicipilfPublic 15 ft. 20 ft. 2" in. 010 SCH-40 PVC
OGeothemlal(lieatingtCooling Supply) °Residential Water Supply(single) ft. ft. in.
OindustriaUGonunercial f)Residential Water Supply(shared) ^
FROM TO MATERIAL EMPIAC SIEXT METUOD A AMOUNT
Dirrigation 0 ft. 7 O. Portland Pour
Non-Water Supply Welt:
ft. n.
61Monitoring bitccowry .
injection Well: n. rt.
OAquifcr•Recharge °Groundwater Remedial ion "_19.SAND/MAX/EL PACK if mrplicabki .-
� FROM. 10 I-MATERLAl, EMPLACEMENT METHOD
° iinderStar:lgeandRccovety °Salinity Ramer 13 ft. 20 ft. FILTER SAND #2
[)Aquifer Test 0Stommatcr Drainage
ft. ft.
°Experimental Technology °Subsidence Control
"20.DRIi,LING`LOG'Winch addiliane)sheets if
❑Geeothermal(ClosedLoop) °Tracer FROM TO DESCRIPTION kdbr,6aWnccr,tuMnick type.grain tlrrr.ttt.) '
°Geothennat(RcatingCooline Return) °Other explain under#21 Remarks) o fi. 3 ft. Sandy clay
3 ft. 17 ft. Rock
4.Date Weu(s)Completed: 1/24/22 Well lD#ma-6 17 ft. 19 ft. Silty sand
5a.Well Location: 19 ft. 20 ft. Rock
MAR 1 12021
Faircloth Machine Shop ft. ft.
Fae.lityOOtyncr Name Facility tDk(if applxahlc)
ft. ft.
2355 Farrington Point Drive SE, Winston-Salem, NC, ft, (f,
27107 Physical Address.City.and Zip 21 REMARKSi._ _ ,
Forsyth Six foot bentonite seal from 7-13'
Conroy Parcel Idernut eitionNo.(PO.) I
5h.Latitude and Longitude in degrsca/minutcs/seconds or decimal degrees: 22.Certification:
(Stool}field,one iatlo09 is sufficient)
)\ 2/18/2022
Signature of.� 7-.u.all Date
6.Is(are)the well(s):,21Pennanent or °Temporary ?1,4"... +/ t' is _.., ne..a
i sti4nit this fen,.. tr , 44 was 1'•c,.I eonvnueted in heenrdonee
with 154 NCACO2C -,:"*'-h t,h %IC-;4200 Well Ckrrrarrncrimt Stamford.;and that a
7.Is this a repair to an existing well: °Yes or IIG$o ropy of this r,voo/has bran jtrnrided to the rirlt owner.
if dais it a repair,fill ten to tarty writ constturtion information and explain the tutrure of rlie
repair under P21 remarks s'rl7ion or on dtr hark of dds foram. 23.Site diagram or additional well details:
You may,use the.back of this page io provide additional well site details or well
S.-Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For aanlriptr Ia/Chinn Or vu-a.nawr turf.'wells ONLY with The some construction.sou cone
safrn it nnc form. SUBMITTAL INSTtr-CTIONS
9.Total well depth below land surface: 20 (fat.) 24a. For AR Wells: Submit this:fonn within 30 days of completion of well
Fortr•uttipk wells list ail deo:1d Ifdifterrnl(example-7@200'and 2el00) constniction to the Cottoning:
10.Static water level below top of easing: (ft.) Division of Water Resources,Information Processing Unit,
Ifnater le'vr)is above robing,use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.6" ('in.) 24b. sir injection Wells ONLY: to addition to sending the font)to the address in
24a above. also submit a copy of this form within 10 days of completion of well
12.Well construction method: Air construction to the following.
ti.c auger.rosary:'cable.direct punk rte.)
Division of Water Resources.l)nderground Injection Control Program,
FOR WATER SUPPLY WILLS ONLY: 1636 Mail Service Center.Raleigh:NC 27699-1636
13a Yield(gpm) Method of teat: 24e.For Water Supply&injection'Wells:
Also submit one copy of this fond Within 31)days of completion of
13b.Disinfection ti ( Amount: well constriction to the county he lth department of the county.where
p" ' �._. ronstnictcd..
Farm OW-I North Catoitna Depannr prof Ent imaurxtt'and Natural Resources-Division of Water Rat sotrtes Revised Ate 2013