GW1--00483_Well Construction - GW1_20240116

` WELL•CONSTRUCTION.RECORD For iNetaal'Use ONLY:
Ellis fanseasN eralCprsinglearnr Milenclla • -
I.Wdi'Cbnti tetorLtForinatidit: . '
. `14.11A1•ER'ZONES. . .9
John Eisenman !MOM 10 DI'SCROPTION
• Well CorttitdvrNaniC • ft. .- . ft.
•
4439A
ff.-• . • .I I - . .
. NC W'eli Caituuelar Ccnifiealioa Neither 1510t1TER CASING troi`nirittg a`seU:ireflsl OR LIN1:R(It'dS'ticabk;):'
'FR011 To DIAMETER.1 : 'TIii KNESr MATERIAL
SAEDACCO f k: ft: I ii; -
01sittrtay-Naag.t: • 36 INNERCASINCOk.T➢MINGleOttmrmate#ue11-eiimp".. _ .
FROM' s TO DIAMETER. 1 THICATTESS' MATERIAL
2.Welt Ceiistruetlnu.liet'tultti: • 0 ft, 30 ' ft. ^2 • bd SCH40 . PVC •
•last ull uNpGrnble rsi N primiTs(re;Catrnry,.,90e.;:Yoriamee;fi ecdOrt.es:)
•ft., ft, in
3,Well.Use(chcrl«sveil usc)t
- _---_- -__ -- • own.. TO DiAstrins SLOT Sin TrliCk81S3 MATRRrAt.
Water Snpph,`Vc�ll:. •
'i711grfcftitural. . iINItailcipal/Pubiio.:
• 30 (t:. 40 ft.. 2 ' 'h ..01b ' •SCH40- PVC
DGeotitermal(Hcating(CoolitigSupply) DResidential'Water Supply(single) rr: rc i1a
DiudustriallConrntercial. '. . DResidcntial Water SuPP '(sl>rttsd)` 1 t 'GROUT . _.. ... -_ -. .. _ .FRROM - TO- MATERIAL - EMPLACEM LNT MEiHOD&AMOUNT .
OIrrigation : • 't? ft: .
'Nsn-Water'Supply Welt: '
�Moluloririg • - . plRecorcty R.• ft.
••Iuleellirtt.Welt .it: ft. ;
rMAq InfcrRCcharS e . IRIClroitlnditilerRcltieclrition• -19 SANDIGRAVEL•PACKpratristicabtet:•--. - - '
R •
FROM TO" . '''.1 THRL1r,• FUk1:ct.liENT M TII011 .
DAAgitifcrStcii$ Indc Rccowiy •C]Salitltty 13imcr' 28 R. 40 ft, sand #2 . .
. ElAgtiefcr Test • ElStortitwatcr Drit tiagc• .
ggwrnmenhl Tceehnologu ❑Subsidcncc Coldrol.- •
0:DRIELINGIOG(all li addltionrit sli&i if ncecssirr kl
OG.othemtal(Closed Lo•op). - ❑7tocer . ' FRos1. 'TO D.DESCRIPTION town rsntrlf«,.iutun culsrxtirx an Kra rlat
❑Geotltottuai(tieating/Coolittg Return},. 00ther(esplain under 021'Retuad s) 0 ''ft.. 40 ft... sand stone.
. ft.' ft. ' .
4..„. . ,...). . .. etials 1-3-24' Well11D T -3 ; -
i • J>;N il:;''
2G24 -.
Factfity,ChvncrNalw Fagtlit)•ID#6f applicable}
ff: -ft:
ft. f-, IrlivFrl .1r1•il l�r ,. 4r,r>:^2 I ir•v
710 Piedmont Triad West Drive ,,Mount Airy, NC, 27030 s'� .30.G
-ft, ft,. !3�slxr', •r a
Plgsrcril•Addtcss.Cit3•.,414--Pp 11~Rk:ALA1iK.S : .
- Surry _ temporary well l ;
• 'Cmiab' • No Ni: 10064:oleo No,(Plat_ ,
1
511;i.auftidc und.L,iing tnliein llegtmcrdiiiiieutsalscconds tir decitiiill de rcccs; 22,Cckfit)crofioti: .
'(ttxdl.herd,ooela1Jlotia is;s11fRiekrti) • . .
i
Stgmtia^ r n' w!lt vr �r;�`- - — Dale
6.Is.(aru)thewell(s): DPeralanent or . IETeinporarv. ',hirrc.,/e�. - ,./- -i••,yca•--a
#)..signs q,d.ris.te,, 4.,rfu •;a n.ri wsr•t.:e:,F.4,:vralnrcred,iir•mrorththce-
' rush!sftiVpICoat::,.,-...,,-r;;,i,r,,.tuk.1017IraCiirstrreiritntSraodardsandIlir:ir ' . .
7.ii tttisarepairtoan.existingweli:; DYeS Or IffiNo . _ctpvofrlrlsrevxrifhal been'provided•rii:ltrilAttlmtner.
if rh(a:tt a repair,fill avr klavuu irrll corasrnnrcrtoa trfarrrurr.nit mot c.lptaln rlie.nrrri,rc of he ••
repiirri id&02i.rivnarki ieeliao tr rn the hook of rfmr forur. ;2 .Site Milli ran[or addilia nut well details:
You Tay.usp.ttie beet of this page.to provide additional well site details or Well .
' 8.Icnan erof wells constructed: 1 • .constinatiaii-details,'You inai•also at ach additional pages if neces"san• '
- For itthliVe lrifeeron nt ocrn mrrvr slrpplytvi'1ls ONLY WWI dtc sasses cosisfrrieilon;you too ••
..514mit one forru.- . - -- Sf 1i3Mf7°FA 1,f NSTUCTIONS I ' .
o.,Totaliscltdepth beta* rxfacei . 40 ...di), 24a. clays.For.All.Wells: 'Subbrnit this'hi�li within 30 of comptction of well
For rulrlphtrwait lice aid i"cprhs l i-ri(ffririrl(ex rropfe-3@2PP'mul2@ lafri can54iuction to lltctortoni lig; 1
I
10.Static water le►;el belcow-top of easing:• • (ft) .iliv isian of-Water ReSoucces,.in• formation Pxaceysing-Unit, •
Mower is*time c®a(li,,,rase".. 1617 Mast•Scivieg t.".Ctitet•,Raleigh,NC 2 7 699-16 17
et.Bartholc dismteter.6 (in) tab,For torrefiilrl 417e1li ONLY: T:addition to sending-the-fort to)he address in
24nab0e.also submit a copy of tliis.iform s~:itlun_(6 days:of completion of well _
112..Wci1 construction intthod:Air .cotlstnicliou to the following
(ic:anger rosary'cable:d'iacct paslictc.)
Division of Water;Resdnrecs,llruderground Injection Control['Ingram,
OR WATER SUPPLY WELLS•ONI.ir 1636 Mall:Scrvicx:Cetltei;Rnleil h,NC 27699-1636 • .
fB;tw lo'reid(g in1) !'lctliod of test: ...4G.For Water Supply Si fn,Lcction Wells:
Also submit One copy of'titis fornil tsithin 30 Idaysof'goulpletion of . •
131i Disfnfe tiuu( per Amount: ,wellconstractian•to the-comity health dcrtarlln:nt of the ccitldy.then •
' constricted. .
ForaiGW t Noah earoltnaNpart rent.ofErnit-mamaatrd-NantralRcraurccs-l)iii;IonoflYaierR uaes - Revised August10l3