GW1--03840_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD 6\°
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I.Well Contractor Information:
14.WATER ZONES
John Eisenman i now TO DESCRIPTION -
V'c11 Commit,'Nam (t. ft.
ft. , ft,
4439
NC Well Co,dniclor Ccniflcatron Nunrbtt 15.OtITER CASING sari-(seta%east OR I INFR l if aii beabk)
PROM . MAMTTFH TIOr'ANPSS I MATT RI AI
SAEDACCO n• n i°'
(oII uo Naar: 111,INNER CASING OR TURING Igsarbermal clued-Iuoyi .
TO .T-DU\IF Tr It TII IC A\ISS MATT RI 11
2.Well Construction Penult k: 0 ft. 35 ft. 2 . SCB-40 PVC
List all applicable*sell primal fie.(. 'in- Sane.Variance.Irfatin(ea.) -
rt. nt it.
3.W'ell 1-se(cheek well user: 17 y SCRUM
--1(
Water SOMA!,Nell: ' PROM I To PIAMP S)TOR SLOT s I 11111WIENS NI%TERIat.
IJAgrwultulal OMnnicipaliPubhc 35 R. 50 ft. O10 SCH-40 PVC 2 to
l lGeothertnal(Heating/Cooling Supply) ❑Residennal Water Suppl isingle) n ft to
I IlndustriabComrnercial OResidcnnal Water Supph l skint't itGR OQT
rMM 70 r1ATERW- EMPLACEMENT METTIOD A.040(\1
❑lmgation 0 n. 30 II. Portland Pour
Non-Water Supply Well: It. n.
•
WMonitonne ❑Recover' i_ -------._______
Injection Well: • n- rt.
•
❑Aquifer Recharge OGroundwatcr Rentcdiation It SANDKr'RAVEL PACK iii arplicablet
❑Aquifer Storage and Recover ❑Saline}Barrier INQM TO w yTTR1yl. ewPl-yl StirNr wt.Trtnn
33 ft. 50 ft, Sand #2
oAquifer Tcst ❑Sttomwsater Drlinage
ft. ft.
❑ENpcnmcntal Teehnoklgs ❑Subsidence(control
a DRILLING LOG(attach additional bee if nccr,.an I
❑Geotler alIC•losedLoupI ❑Tracer nlow TO I DiSCNIP rill\1,6r.1.mraiegg,waYtekgat,VIM lie.ek.I
❑Geothemal IHcatnng+Cooline Return)
DOther iexplain under 021 Remarks) 0 It 50 ft clay/sand
ft. ft.
4.Date W'eAR%)Completed: 6-12-24 Well IDAM14-1R ter- 1. _
4
5L Well Location: ft. ft
Salem Spring Site It, ft. JUN r 8 2014
Foolos r11,kr vane Facility ION inapplicable) 1
R. R.
303 waughtoyrn St., Winston-Salem, NC, 27127 h. r ift1b`lfrii f A P,r-swe--1 U
n-1 D Cyr 043
PMsical Address Cis.and Ztp 1L REMARKS
Forsyth ' Bentonite seal from 30-3:3'
('oumN I'-u.d I.leuldleainn No INN I
5b.Latitude and Longitude in degr es:Minutes:Seconds or decimal degrees: 22.Certification:
(swell field,one raptors is sufflei0atl
W � �_` 6/17/2024
-Signature ofj r:^' ,:�11 ..race);! -- [I— lk
6.Is Iarc)the wrllls): X Permanent r temporary By signing this Jtul..c .TC,, ;ile k,9:�x a s,. conrnurred is a rorrhmer
with/SA NCAC 02C-•x----Y::il'.4. oil1 .0200 Well Consent non St ndoe 1.,Nut rho,l
7.to this a repair to an existing well: ::_i Yes or ENo COO'Mitre rru oil hot Oren prorated to Ile Nell owner.
If rhis it N repair.fill ma AMora it ell,.N$llrt ll.MO NI/OrMMBoml and r t'piN0,1 tin uwrare of rho
repair under 121 remlar.k,section,or on the hart of this forum. 23.Site diagram or additional w ell details:
You may use the back of this page to proside additional well site details or well
8.Number of wells colastrwYtd• 1 construction details. You Inas also attach additional pages if necessary.
For maniple lnkcoos1 of N.NI-Mellor,upplm Rah ONLY m'ah leer nlllle rlalStrlwflol,.volt urn.
.saMrit.Mu fonro- SUBMITTAL INSTUCTIONS
9.Total wdl depth below laud surface: 50 (11.) 24a. Fur All Walt.: Submit Ihis faun within 10 days of completion of well
For maniple is-ells list an depth,if different tettnapre-is ?Ik1.nut 20 f00'i constnrction to the following
1U.Static water ks-el below top of casing: (ry,h Division of Water Resources,Information Processing 1 nit.
If.uao,h.\rl n 0.'1 r I ming.au.'+ 1617 Mail Service('enter,Raleigh,N(-2 7699-16 1 7
I I.Borehole diameter.8.25" (in.) 24b.For[niceties Wells ONLY: In addition to sending die form to the address in
24a those. also submit a copy of this form within 10 days of completion of well
12.Well construction method: HSA ea titUctiun to die following.
II e.anger.rotan.cable.dirce push:cr:1
Dhlsion of Water Resources,llndcrpvond Injection Control Program.
FOR WATER SITPLY WELLS ONLY: 1636 Mail Sen-lee Center.Raleigh.NC 27699-1636
13a Yield It pule 24c.For N Ater Nuppls ti Injection Wilk:
Method of test:
Also submit one cops of this form us this to dat s of completion of
1311 Disinfection t)Ile: Anrannt __ well constm county cnon to the county health department of the coun where
• constructed -
Font GW-1 North Carolina Dcpanntcnt of Lot uoluirlu and Natural RCSOlneei-Dicssba of Wince RaonrCIIS Nei lad August N113