GW1--05701_Well Construction - GW1_20230905

. -
WELL.CONSTRUCTION.RECORD Fes'friend tke.pNLY:'.
'-11i.form call:411.mi for:singTour multiple wills. - •
. . . . .
1.WiiI1COotOtetoir Informatioti:. • ,
. .
-4 4:-.WAVTER ZONES • , t' ',• ' , . • • . . • '
Stefan Smith ' FROAI. TO •DESCHIRTION '
Well CoiltrdelorName. ft:
ft. if. .. . .
. . . . .
3576-A
15."OUTER.CASINGtaritifillkiiiitMetlsVOR LINEKtIfla tlOiblat -,-. ' __. •
WWI Contractor Cot ificitionNturher
MOM TO - . DEAttlETElt - .TRICKNESS - MATERIAL
SAHDACCO . . • ' .fit .it. • I, l• III; - • '•. .
Company Norte. • .16'ANNER C.ASING ORTUBING 4gei)illeritiaretuki14060);,•:.' ... -. .
' FROM ,.,.TO DIAMETER 'RUMNESS MATERIAL
,2.1Arc.litottstrtiction Fat*f;: . 0 ft, 10 ft. 1 I, .;1316 SCH-40 PVC
Lir:i Oft applicable ssill puitris 04.7.-Cpunry.;Sloth,Variant:J.,fled*oro ,. .
-ft, . •ft. ; •in.
.. , . .
3.'W.cil..Usr.(0416ridll ascii ' -1?.SCREEN- WaigESDIllay Well:'
.FROM• , TO ' •DIAMETER , SLOTSIZT, 1 IIIICKNESS- I 5IATERIA L
10 " ft,- 20 'ft: 1 '111. ' .010 SCH-40 PVC
ElAgricuititral. Cihhinielpal/Flibite .,
N. ' •
•
Metithennal(Heating/CoolinESUpplY). 13Residetitiai.Watet%Supiit.'(single) . • ' 're'' in'' .- . • .
. . • , -•
0 indusitiai/Comaterciel. CiResidentiai Water OF GROUT Supplj:(shared) _ ''en.0„ '--
MATERIAL 1 EMPLACEMEiT NIMROD s.AMOUNT
El lerleation' . . . . . ..ft..' ft.-
. . • . 1:
• -No U;Water Supply Wen: • . . . ' -.•- . .. . . . ,. . . . . .
__ • .
• 1112MatiiIcjeug IDRecovety . • . . .
Injection Well: • ft.
• ClAirnifet
R, liarga
. . . EGOu nd-w•atcr Rc ificdation t92SANDIGRAV EL.PACKtit a•ppli'ea he ,
. .. ._. . . • ,... Ba - -FROM TO' MATRIA " -•E-M.,P.:-L'A-C.-: E NT,-M-:E-TRE=W
Amifr.Snage and Recotty CiSalinity Harrier ft ft ' '
f---- -
• .
0 fytniter Test ClSloinittiteit5nlionv . • " •
. . It. . Ji.
itiEVerimciital Teclmolog .• 13SnitSidencc.eotenti I.
• -14;18RILLINGLOGInftaitt4dtfltioikil'ik,etiif necastini
- dcieeithent41 Closed Loup) bl'ilicer• FROM I TO '- DESCRIPTION embr.hardneounietiotmiwn ore.dm
. .
OGeothennal(lleatinglCoolitig Return). • Diller(explain under.#2 1 Retualks) , ' ,f, ft,
, .
.
. .
it. • ft.
4.Date Well(s)Co pipletedt.8/16/23 Wen ID#136 .
ft. ' ft.
• -
54;Well LOcatton't . ft. ft. !, -C"';',, .i•-
. ‘ r.-6 ......,-;1 ii.:c-'1
' N,-,....*1-; k 1...,
Forest Oaks Circle K ft.. ft. . . ,
,. . .
FacilityMivmr,.Nann FaCpiw ipN(lt.oppiiF-tibte) ' . ft '--- ---:--------SEP-0-'5102-j
.-
5324 Liberty Rd., Greensboro, NC, 27406 ft.• ft: ,; 4.. :G
••• •
INI.riaztcn Pr-v.1.04o uji
"''• - •4
•. 016-tiod'Aoi..s ss,-.cay_-..apii*ip'• ,2 t:REMARKS' •,
,, . DVVOA'0474 • '-
Guilford Temporary well for grab sample
'.-
ecomity Parcel fikilliftealloti No,(PIN) . . . • • I,
$6,:.LiotitisOciiii.t4neictite in degrces—tOitutestssec.tiOs orcleciti4 degrees; 22.cmitiikati,,,,m.Omar:eta,uric imiloti is•-iliffkiee1)
•i .8
N • w' ..-I 4; likvais,lv :: 8/24/2023.
Si '.flt of Ee..lied Ilia Catfiractail' ' Date . .
6.18(are)the'well(8): CIPernioeut al' Xifenquirpq *xlgning this ftr.imi.1 hereby erectly ilia ila wellfsl war(vere.)eiinyinictril lir.qqeolOrner
with.15A.NC4C 02C,0190 or 111:NcriC.Q2C,p20 Well Cousliticritur Storafkrtis ond Mar el
7,I.this a repair to an existhagwellit EIVini- or No reirry•.of this iroinf hiii&en provider,fit.the srai On7iir,
If 1hfs'.1%-o rtip(slr.fill Or bolsi'Wrll osIssuiradoli livisnriationiteirl jsp(o)n the riarore of the
repair ru ,021:rernarki,...4ega On u5 n at c,bark of thisfornr.". .13:40 de e illAgr ant or adttltiopitli.w11,t!ettiiiits:
You play use the.back of this page toiproVide"additiOnai well Site details or Well
IL Nuntherof Wells Constructed: 1 eousuuetion details. You inay itlsO.atta'elt itddillottal pages if necessary.
For JUAN&kfailon or oonqrarer supply let'lI*ONLY midithe.srung-coostrodion,you curl sufzulir osie form. strmarrakr,NsTucTioNA ,.
0.Tot41wat dCpg;below iand stirfueit 20' . - (ft) 24a. Far AU Welk:: Submit this:fomt within 30 days-of•completiOn'of welt
For ioulalple irells Ho all rfeprizt irdefferent(excarripfe.,3@.200'44112@l00) 'constmetion to the following: - ;; . '.
P . .
fa;Static water turdbeloW top of casing: (I'..) Misfit!'uf Water Resauree8,fnforniutina Fineessing Unit,
*yaw teed lv above Cos*.itse."+" 1(17 Ataitservice icr!ntcr,lialkigh,NC-27699-1617.
.l• 1
it.Borehide diameter:2,25" •'On.) 24b.For To reetion Viklls.ONLY: hi addition tosending.the Than to the address in. '
240 above,also submit a.copy Of this faint within 30-'days'of completion-of Well
12..Well coustmetion method:DPT - . constnielimi Co the following:: 1 ,
(Lc.putei;ialary,cOlet'dirr_cl.litstt.d0 • 1 ,
• . - . DiviSioit of Water Resources,Underground r on Control.Program,
FOR WATER SUPPLY WELLS ONLY' 1636 Milt Service tit'alter,Raleigh,NC 27699-1636
i.
•
24e.For Water Supply eft hie jecthwil Welts:.
113a,lficld WO AlTeihoti pi test:
Also submit'one'copy of this form within 30,dayS of completitt.of
13b.Disinteetiontniet Amount:' ,well constriction-to the county heahh department pf thes county where
.
. . constructed.
FbrntGW-I North Cotolina Disperimentof Et:Mamma's a0 Natural Resources-DIvis too o'f Waiek Ri.nrces Revised Augtot1013
1 .