GW1--01289_Well Construction - GW1_20240229

WELL CONSTRUCTION RECORD Far itrscnti1UscONLV:
This form can bc used for singleor tnaltipk cells
01) .
1.Well Contractor Ittformation: ��
°ta;%t.TitRZONES .
Rich Lemire - FROM TO .-DFSCRIPTIDS"
Well Cutaraaot Name R> rt.
2593A- • rt.. rt. I, •
'
NCWcllCositracadrCcaiIicalieANruibct is.OUTER CASING(foretutltcu'stl cfls)°R MERidni flratik}:
FROM III DW3IETEn. THICKNESS MATERIAL
SI EDACCo ft. . ft.- I ilL -
Contp,ur}•Nam • 't6:INNER-CASING OR-TUBINGG igsnkermal crowd-loop)i '
FROM TO DLA.M1IeTHR. T(1(CKNP.SS MATERIAL
2.Welt Construction Penult#: 0 'ft. 47.5 ft. '2" in SCH-40 - 'PVC
us:all applicable rrvllpe)mih(Le.County.Stare,-arariaue.tryatC4telrj •rt rt. - ' In.
3.Welt Use(check:well use): t7 SCRi:EN • -
'Wutersuppay Well. FROM.- . TO •DtAMP.T1;R s Lot sPFL TIIICKN MS mammal.
Cltlguieultutal . CDMunicipalt'Pttbl,c 47.SR. 52.5 R. 2" in• .010 SCH-40 PVC
®Geothermal(Heating,'Cootitlg Supply) IDResidential Water Supply(single) it. R. tn.
• I7lttdusiria11Contntercial • . ©Residential Water Supply(sh at d) .t:a:GROUT - - •
-
FROM Ttl MATERIAL - HMPLACL'MMT METHOD&AMOUNT
Ohtigotion - . . , 0 ft.. 43 ft. PORTLAND 'TREMMIE
Min-Water Suppls.Weli: - • R. R. '
In Monitoring pRccmely . . . ,
. Injection Well: - R.- ft. .
®Aquifer Recharge DGioundtsritcr Renicdiation °t9:SAND/GRAVEL•PACK IN tyipncabte)• - -
'F1tOM ' To - MATERWt. : E11Pt,A(:}:M1IEVTMcsnio t
DAgniferStoragc and Recovcty (]Salinity Barrier 45 ft. 52.5 ft. SAND #2
. IJAgtiifcr Test- ❑Stormwatcr 1?rainage•
• R. ft.
Dl:V.rintcNal Tccitnglggy ❑SitbSidesaCC Control :2n.DRILIANG LOG(attach nddttiotial'streeta if itccessan-1
OGeotheimat(ClosedLoop) Cancer. F11oM 10 • • DESCRIPTION finbnbnnlnc_1+.wR'meklhit.tratnwack.}
tJGeolheimal(Heating/Cooling Return) ®Other(espiniitmnier it Retuaths) 0 ft. 35 ft . REDSILTY SAND .
' 35 •ft. 50 ft.; SAPERLITE '
4.Date Well(s)Completed: 2-8-2024 wen W#A -2. 50
tMe
it. 52.5 ft PWR . 1. 'r`, .
Sa.Well attoo: 52.5 ft.- it.,- ROCK . I 1 C(.0
V h:. tf 6 VE
L.
FacilityA7noerNanM Facility 1Dk.(iiupplicabic) R FC�. ft. 4 1T [/fz4
U
850 N. Liberty St., WINSTON-SALEM, NC, 27101 ri. . fL.. ill'fOr n en 7r,„,,� p t
PI1-sieal Addiess.City.and Zip• a21.REMARKS - t7*C a 1J
FORSYTH BENTONITE FROM 43' TO 45'. •
County Patic11denlifteilionNu.(PIN) - '
Sb.Latilildc slid Longitude in dcgnces&minutcslsecdnds or decimal degrees: 22 CcrtllicaHona - .
or well field,oak Inttlong Is sufficient)
•
11 - W ~° f d.+�G. 2,11,2.24
. Sigtrnureaftcitif ..,,,,,,„,, ,,-.0,-,.,- Dale -
6.Is.(are)We tt'CII(s): SJPtniialll'LLI .01 nTemporaty 'try slgnmb thir funrr.'I&erebi•certify rhru the,Pellfsl rsw:fNrta)cYnrtrucrerl lrr ai rordirkm
With 1551 NCAC OW MOO or.1 Srt NCIIC 02C.020011 Well Construe"ri'ou Stdiulards and rl s:a
7.Is this-a repair to an existing well; €1Yes or 'fig No •C.,(iy'ofWI record hasiirtnpmvirled ratha well owner
ifthls'ds n n•Nair;fill out krivim well colutnrc1Moahrforooriott and riplahr rlie aware of rho
rrpa ct:o derd21 iedurrkr-rcririu gran the beck ofthik form 23.Site diagram or additional well derails:
You-May use the back of this page to.prov'iide additional well site details or well
• 8.Number of•wells constructed: 1 - - . coustmctiandetails. You may also at act:additional pag s if necessary. .
Form:11 pk(*etlonorriot-pvtrer_supply'_sellsONLYreinrhostttritCarrslemiliorr,youo n j
submit-ono form. SUBMITTAL INSTUCTIONS
9.Total welldepth below-land surface: 52.5 • . ((p,) 24a.For All Wells; Submit this-fano within 30 days of completion of well •
Foe mol7r&wells list alldepths If&Area;(example-3E100'dad 2@MO) Construction to the following; . '
1(I.Static water hn'el below top of casing: 37 - - {(}t,) • - Division of Water Resources,Information Processing-Unit,
if luturrkrel Lc above easlax rue"+" - 1617 Mail Service Center,Raleigh,NC 27699-IG 17_ .
11.Illarcho1e diameter:8.25" ,(In.) 24h.Car Gelocdott Wells ONLY: In addition to sending the foml to the address in
24a above.also submit a copy of this Ann within 30 days of.completion of well
12.Well coustn(ction method:AUGER - cotlslmetton to the follodring: 1
(Lc.auger.rotary,baby(tisect NAM.) i ' -
Division of Water Resources,Underground Injection Control Program;
FOR WATER SUPPLY WELLS ONLY: 1636 Loll Service Center.Raleigh.NC 27699.1636
f3a.Yield(gpm) • Method of test: 21a-For WaterSupdtly&Injection Wells:
Also submit One copy of this fonn,''within 30.daysofcoutpletionof
131t.Disinfection type: • •- Amount: . . . well cot:stoiction to the county health department of the county.where
constricted.
Faun Mit-t Nardi Catalina Dspartntetu of Enuiraruuuit and Natural Resources=Division of WaierRecatrte; Rci-ised August201'3
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