GW1-2021-02259_Well Construction - GW1_20210512

WELL CONSTRUCTION RECORD � For liacmal Use ONJ_Y:
This form can tc usM rem singes or nmltipk.xeeis
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1.Well Contractor Information; 1
14.WA'=R ZONES
Rich Lemire FROMI Tt) DFSt•RIP,17t1N
U'ctl Coi4nc{4r Nlret>r ft. ft.
2593A
NC Well Calnricior Cotifrcation Number TER CASf.1G ror martlkwAd nens OR L1KfM of applicable)
i FROM I TO KAMMIR THICK-NMSS I MATTRIAL
SAEDACCO Inc 0 ft, 1 201 ft, 2^ in. SCE-40 PVC i
Cangrun NSsne 16.INNER CASING OR 77.+BING iWalktsti_t_fa_1 elotada?OPL__
i FROM e TO I DLiHETF,R TIMIKIVESS MLITLR1.iL
1. Well Construction Permit#: ft. ft o� -
idtt erll alrprlir uble^rlf penrri;r(i_r.Cotoih .Si nr,l arirar:r.hRELJrl�rtr.t Y_.__ .-_.-t --— _. _- - -
n. I, in
3.Well hsc(chcelc well use): 17.SCRUN
Water Supply Well: FROM TO DIXURTFR� SritiYSM I THICKNFSS I MATERIAI.
rlAgriculturif Clhlatticip:lllT'ttblic 20- ft. . 301 ft. 2^ in. 010 SCS-40 j PVC
010cothemtal ftming-lCooling Supply) UResidential Water Supph•(single) ft. ft.
I lndustrial`Comntercial I)Residcntkil►canter Soppy(slrarcd) 18_GROUT
FROF1 TO M1ATEtlC�l @110LiitMl2NT\iE7111101)fi.010UNT a
oh-rigalion d 0 ft. 1 16- (t. PORTLAND TREMMIE
1lon4l'ater Supply Well:
Mbionitorke ❑Recmcn• ft
injeetionWell: ft. ft
❑Aquifer Rcchar is 0-Groundwater Rcnickition 44,SANDIGRA►EL PACK(it eilieabte
FROM -in111TF;RL.i1. K:MPI.AI1 iliN7 Mr'rflrlla r
❑Agtiifcr Stor,>Gc n>1 Rccq�'cr?' ❑Satini>< f3arricr 181 ft, 301 A. SAND #2
❑Aquifer Test ❑5tommatcr Drainage ft. ft.
❑ExTcrinicntat Tochnolpgy ❑Sttbsidcncc Control
ui.QRILLiNC iAG(attach additional sheela it mecesstin•)
❑Qodietmal(Closed Loup) oTrdcrT I FROM I TO I DFMRIPTIOMtot)r,harenc++,wi4nn•kN n*ra aiGl
❑G ifienno l MeatinetCuofiue Return) ❑Outer(explain_under 1k21 Reniarlks) I 0 ft. 1 30, ft. 1 RED SILTY SAND
• tl. tt.
3.Date Well(q)Completed: 4-30-2021 Weal il)#MW-14R I h. it tq t�
52.Well larcati In: (t. ft.
SAMS CURB MARKET ft. ft.FaciMy.-DwrsrrNanse Facility IM"fifapplicable) A�/ft. } f1. __ F._._. =. R�(-,Yd 1 2_.. 0z1_=..,z_..._
4215 N. Liberty St., WINSTON-SALEM, NC, 27105 At. Frt. lnforrr-atron f
PhysicalAddrss Cih.:IndZiP 2LREMARICS _B
FORSYTH BENTONITE FROM 161TO 181. 1
(:onulr NmO hki irieadimiNo.(t INI ,.
5h.Latitude and longitude in dclmrs/minutcstscconds nr dl,•cimal dcgrccs: 22.Certification:cif cell fseld.rMec W-16ri_•is sultu;h;id)
K �ti' '-� �"�?/Ms.. t. 5/2/2021
Sigmiu^ofCcni s:V'd1 Contrrior Dme
6.is(are)the well(%): 10Pennancn[ or ❑Temporar.
N+ a'rgnrnl�Air rem^.1 irrrrl!r re•rri(c rh(!J lhr nr(li,+)kry(were)4urntn-rtrrl irr ot•.c,rrlrmre
"•illt 15:1.NC W 02C,I)10?or 15A IC t(-Q+,C,0�11V lVe•(1 Gnwrrn rion Gnrylorile?old rl:,ii o
7.Is thip a repair to an existing well: DVc% or KNo oy)r@idet reroof brtsllull pmridwd ro JIH•:ero:Y un nrr.
Ifrhix ice et'lseir,�ilanit CiTnrrta^'rllcernirnr hrrr injtnirprrir,n?rnr1.'tgrlrriq rin nr:rrri.,J'tih
repairierrrlrr8'1 rrrnrrrk�sr:•iim.ur rx•e rhr bu•k r:J'Pliis f,nn. 23.Site diagram or additional well details:
Y(:qI may use the back of this page;to provide additional treil site details or well
8.Numberof wells constructed: 1 ams[tuctlon delatts. You nutr also aftacAl additionat pages if ix-cesstn).
For rnnlriltlr ji ikwrlmi a:towi-wooref S„rt-i+wells ONLY-iorh the urme"ursrr4wdMi.:4.-v rein
auhntirnnr form. SUBMITTAL INNTUCTIOIN4
9.Total well depth beloi%land surface: 30 24a. For All Wells: Subunit this funs within ?u days of completion of well
For rnriltiple rcr110ilt rr(l r1r/ttbr'ifdifli•re•nt Grp)) construction IO the folloninir
IU.Static water level below top of casing: 24 (1t.) Division of Water Resources,Information Processing Unit.
I,I:r�ttrr lrtt•1 is irbrece rvs(n;.r,_k ^+" t6171Nail'Serviee Center,Raleigh,NC 2 7699-1617
11.Borehole diameter:8.25" (in.) 2J6- F—ar lljolon V;N ONIN: In addition to.sending the font to the address in
24a above. also submit a Itopy of this futt i within 0 dai's of completion of well
12.Well construction wabod:AUGER construction to the fulluwin_e.
t i.e.auger.rotas•.cable.diced paste ete.l
Division or Water Resouvees,Underground lnjection Control Program,
FOR WATER SUPPLi'WELLS O`LV: 1636 Mail Service tenter.Raleigh.ETC 276"4636
13a,Vidd(gpm) Method of test: 21c.For Water Suppy&injection Well%:
Also submit otie. copy of this fictni %vilhin 0 d4sofconlpletiou0f
13b.Disinfection type: Amuunh- well consiniction to the county health dcpartnmit of the crnutty whetc
— - constnictcd
Faun G►1r-I Nonh Caroltua D,,p ntiteut of Eriitirowixiii:sttd Natiwd Resources-Mvis ion of i!cdci Rinotran Revised August