GW1-2021-03018_Well Construction - GW1_20210527

I
WELL CONSTRUMON RECORD
nis form can be asvd for,sftk or m&q*wells
t.Wd[:Contractor.tntormation:
t4X1+1►�'ItIt7A tom_, .
Dylan Fierst no" 10 Do 11PrrO:v
Well CorMmalorName 27 R. 37 R. PWR
R. R.
4507-A
NC Well Commetor certllication Number f F,lt GtiASTNt3` driax►'tt lint 11 IfCabk
FRROMOM TU DTAtNETBrt TIttl'KiM A4AtERJA4
SASDACCO Inc 0 R. 22 ha 1" it. SCH-40 PVC
t '[N'31Fdt,, ., Nf:' 1t . Wt;- i' 'ttliia
!' FROM TO )r'l DTAM w TIUMNFM I MAMMAL
2.Well Constraction Permit#: R. ft. �
1ja 111,1wirnblr wwI prrrarrx(l c:Cmmrg,sudr.t'arianer.Ir�ec en r1r l
R. R.
3.Wdi Use(check well ase): 7:
Water Supply Well., FROM TO WArlrPfi R .dT trs: T1nt7fMt5S MATRRrAi,
DAgrkutltnal DMnn'icipal/Pttblic 22 tt. 37 R. 1 1- 1m .016 SCH-40 PVC
(30001tw1nml(Hentingtooling-Sttpplp) OResidential Water St7ply tsingle) ft. fL tb
DindusuiaVOrnot"cial DResidential Water Supply(sbared)
,FRROM! TO -MATERIAL
A 81lTPI.A MEfl100
fi AMOUNT
01trigation
i
Not1�W8tCY�DpTllf��T{:
�Motlitori loRecas
Tnjoetoo Well: R:
pAgaif�ltecfigrgc OGrotmdwatcr itemodiation Fa„ TO Art Qu►
QAgaitctSto and OSalin' Barrier 1. trMt�ta rr��Hrrrtr0u.,,
�e �' � 20 R. 37 (1. FILTER SAND #2
OAgtdfcr Tcso O5tonmwtcr VlWn ig
CmVcrin="1Tcchnotogy OSubsidcocc'Contral
2ti DR1t `(�T ad7iddtt7Fits alutts f.
DGeothemml(Closed Loop) oTmcer FROM I TO DtrSCTiJr'rt0?t error Mt at e�
OGMtheMlal(HcafipjdCaoft Return ❑Otter- in under#21 RenTatlts IL (L
R. R.
4.Date Well(s)Completed: 5/4/2021 Well IDAGP-1
(L (L I
St.'ell i.oeatlon: R, ft.
BPHS Transport System M (L
Facelcq•rF wwr Name Fecft iDii t fepplim6k) R. tt.
1511 Pleasant Ridge Road, Greensboro, NC, 27409 iL R Olt
.
�T ton Prooe�sing
pks'ml Address.CRY-and Zip 2UXE1%lARKS. :_, A_
Guilford Temporary well
C.oamy, Pane!tdcmifiCailor;Nc,(PIN)
-%.l,altit adc and L6ngitode in degrecsfinl uteslscsvnds ur decimal dlgvw 2L Ctrtifccation:
{itwEll flcld,oru tatrlortg Is s�dllticraj
36.125081 N -79.961259 W" 5/4/2021
Sigurnic ofCeilifwd WdtCoi uaftr D21c
6.Is(are)the wdi(s): oPertmaneat or zTemporar'y br signing ikt fom,It het04*Pfifv rhim the n+e14a7 sactr{wmv)v6ntrhnmd by oeonrrlm oe
o•lrh ISA NCACOtt,01W sr111 KCAC 02C 42(10Wa11 Ca)Wwdon Smndmesand fiata
7,is this a repair to an a didng well: Oyes or MNo cq)y of rhir rwor dhasl»peftk esr!1n 46 siril order.
lfdlls lT n Irfpntr,fit W 4WM4 W41 CORr1raMM ktfOnr 100 Nd rAptObt 40-M01fe of Ot
repair anderd2l awarks Brawn er an die burl of rNs fi"m. 23.Site diagram or adMonal well details:
You may use.the back of this page to provide additional well site details or well
S.Nomberof wells m0rueted: 1 Construction details. I'ou they also Roach additional pages if tececsaly.
For maNIde loWrlon.or non-»+err suP,ptr tMij ONLY ntth rho some twnsftwr n jWV ran
sxbmte tmr form SUONUl'1"1 I.111tCti'g`a,UCT16NS
9.Total weil depth below land surface: 37 (A,) 249. For Art Wells: Sobmit iftis 4don itithin 39 d*,,s of'conyJh:tion of hell
Fornratrlatr aurlis liar afi,&Whs j'dijfrrms constmcdon to the fettom nV,
lb.Static water level helot+-top of casing (ft.) Division of Water Resmtrees.Information iPnncessing Unit,
ibifi lliati Service Cetttier RaT NC 27699-1617
1/murr level isaba u edsldg;l m"#" r
11.Bo1r11oM diameter 2.25^ ten.) tab.f tlr inirrtlon We11s ONLY: !Tn addition to sending me form to ft addmss in
24sabove. also submit a copy of This form within 30 days of completion of°ur:l
12.NN`ell Congr getion method. DPT GCni1111ttiflD t0 tht:lbllotvir>g
(Le.anger,mtar?•,cmbte.does push.ak.)
Division of Water Rem rcex,UTidergrqund Injection Contrrtl Program,
FOR WATER SUPPLY WELLS ONLY. 1636 Mail Service Center,RalefStt NC 276"4636
13a.1 idol(gpm) Method of test 2.4c.For Wain^Supply&LaJoetom,Wells:
Also submit one Toff of this form 41thin 30 dap of completion of
13b.ilisinfcedon tv)3r~ Amount: wcli constnlclion to ft County h6hi delmament of the cotmtytvhear
aonstnJctod>
runt Ga1Y-t Noah Carolina Dcpmrtmcnt of fsa►°imnmm t and Munn]Raowws-D.h istan of WalarR'6avoes Rcvlsed AL%10 2013