__20220311 (2)

WELL CONSTRUCTION RECORD For Infernal use ONLY:
This.form can be used for single or mult ipk+irfis'
1.Well Contractor Information:
14.WATER ZONCS ` _
John Eisenman FROM TO DESGRIPTTON
WciI Corilrretor Name ft. ft.
ft. ft.
4439A
NC Well Comractor Certification Number IS."OUTER CASING(for aluht<ated rens)OR LINER(if ay ticabk)
FROM TO DIAMETER- THICKNESS MATERIAL_
SAEDACCO Inc 0 h. 10 h. 2" in. SCH-40 PVC
Company Nark 16.INNER CASING OR TUBING igeolbenaal etoscddoop) .
n FROM I TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit*: ft. ft. in.
Lill all app irahlr Writ permit.(i.e.County.Sint%,_Variance.1Rfa't)dt fir.)
h. ft. Im.
3.Well Ilse(check well use): .17-SCREEN .'..
Water Supply Well: FROM TO DIAMETER SI:OTSI7.E TRICKS/SS 1 MATERIAL
10 D. 15 D. 2" in. .010 SCH-40 PVC
0 Agticultu nil OMtinicip lPtlblic
OGeotbemtal(lflcatingICooling Supply) DResidential Water Supply(single') ft. ft. in,
18.GROUT
0inchistriatiCommercial 13Residential Water Supply(slured) FROM To MATERIAL EMPLACEMENT MF.tIIOD 4 AMOUNT
❑irrigation 0 ft. 3 ft. Portland Pour
Non-Water Supply Well:
ft. h.
tlMoniloring ORccovcsy
injection Well: ft. ft.
OAquifcrRcchargc OGroundstatcr Rcmcdiation =19.SAND/GRAVEL PACK Of apptkahk)
FROM TO I MATERAAAI. EMPLACES ENT METHOD
❑Aquifer Storage and Rcco►'ciy °Salinity Harrier 8 ft. 15 ft. FILTER SAND 112
CIAquifer Test OStommaier Drainage
ft. ft.
OF serimcnrnI T.hnologg OStibsidence Control
20 DRII.UNG LOG(attach additional slices ifnceessarsi
OGeothennal(Closed Loop) °Tracer rRoM To DESCRIPTION(color.lowdown.volVrtckhpr,ttrain skin dt.1
❑Geotherllal(Heating'Cooline Room) Dottier(explain under#2l Remarks) 0 ft. 2 ft. sandy clay
2 ft. 5 ft. Sandy silt
4.Dat Wcll(s)Conipleted: 1/25/22 Weil m*MW-e
5 it. 13 ft. Silty clay
Sa.Well Location: 13 h. 15 ft. Sandy clay _ f
Fairc loth Machine Shop h. ft. Al A
Facilnri'Orcner Name Facility lot(if appliaahtcj h. rt. 611ay B �—C-
2.)
2355 Farrington Point Drive SE, Winston-Salem, NC, ft, ft.
27107 Physical Address.City.and Zip -2'1:RPMARKS'
Forsyth Five foot bentonite seal from 3-8'
County Parcel td mriticationNo,CNN) i
Sh.Latitude and Longitude in degnvs/minutc/scennds Or decimal degrees: 22.Ccr[ification•
(if%sal)field,one!ardor!is stdlicwnn
N W >--- _--r... - 2/18/2022
Signature or,r; . ,m u;l Data
6.Is(are)the well(s): _S IPennanent or DTemporan' ,-.signing h ..,. ..t it 's "'""p"�.,�../ ., ,r..t;. zwavitutteel in cavedernee
with 154 141C4C 02C.' -+47 ft 72 Lie. dC•.0200 Well Coutmatetk u Standards and drat a
7.Is this a repair to an existing well: ElYes or MNti copy of ddr rrronl has been provided ed to dn.'Ni ll owner,
If this in a'emir,fill tort trunen well eonsrnrrtin,lnfornuarlon and exdlaln ay nature of the
repair under b21 remarks ettian or m the hark at this farm 23.Site diagram or additional well.details:
You May use the back of this page to provide additional well site details or well
8.Number of we'll coitstnteted: 1 consuuctioli details. You'tnay also attach additional pages if necessary.
For multiple injection or non-nearer smpplr wells ONLY with the some construction,you can
s-alnn,if tow f inn. SIIBMITTAI jNSTIICTIONS
9.Total well depth below land surface: 15 (ft.) 24a. For MI Wells:. Submit this fonn within 30 days of completion of well
For mulrlpk wells list all depths If different(example- 0.!, 00'awl 2*!IDO') construction to the following;
10.Static water level below top of casing: (ft.) Division of Water Resorirces,Information Processing Unh,
If leafier level is above rising,use"`" 1617 Mail Service Center,Raleigh,NC 2 7699-16 1 7
r
II.Borehole diameter:10.5" (in.) 24b.For lnkcdon Wells ONLY: In addition to sending the form to the addressin
24a above. also submit a cope of this hum within 10 days of completion of well
12.Well construction method: HSA constntetiou to the following:
(i c.rogee rotary.cable.direct posh etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh.NC'27699-1636
13a lidA(fipm) Method of tit 24c.For Water Supply&Injccti in;Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health deportment of the county.where
""" "" constmcied I
Form GW-1 North Cstolina D.pannenm of Environment and Natural Resources-Division of Nraier;ResotrrZ Revised August 21113