GW1-2021-07859_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD Pei I ttcntni Use OAY—
Cann cult bc:ttscd CorSirzlcor mtfltiPle wclis
I.Wetl CoutrtctorLeTottution:
14aAYA`i'R ZONES
John Eisenman FROM 10 1 Mc VINI
�Yeil t<tsi4ndnt ishnt+:, fi. fl.
4439A
I. .
Nc Well Contii6arCcrtifecetionNuynb a 15..0[ITESCi4Sfb7G(f+�rm�rTtl ia4lweFls ORUNER4,94`'Fca
FROM I T@ PUM4rTER THICKNM MAiERTAL
SAEDACCO Inc 0 fL. 1 48 it 2" a. SCH-40 PVC
CatIVrutp Natttr 16A.NNE-5t ING`OR'TUBIflTG,` (hera3 etrittda,3ri
FROAr TO D1101ETER TMCKNESS AtAMML
2.Wilt 4Congive'tion 0crittit 4., R.. tt. 'tt►:
lrrt xrlixrl ?irril!e wrfl}irinciPx ftr.:Cmrnry's4te.;.lfadamet,Ti aftat mn:3 R H,. in
3.Well,ow(tk'd;iwcll 05e}:
Water Supply Well: TR0,%t I To I D1A1,1i:MR I sttr.►Tstrx I TttlCtcntNs I MArt atA1,
13ASrieuhilrti G1Minit1pallPublic 48 ft. 50 M 21, In oi0 SCH-40 PVC
0G9atk'f1M21(Heating/Cooling >trA Y Sr l ") Mesidentisl'%l to Su rt. rr. in,
pph'(single)
0iadustiial/commercial OResidential Water5il 19..`.GR Ur,
_ ,.� � �._.,•_'� ��,.
ppl}'(511t.Rd) FROAr Ttl ATATSRUL Pt0 C idiDN'tMrMOD&AMOUNT
01di ottpn 0 ft. 45 ft. Portland Tremmie
Non-Water Supply Well: �
bwnitOFin [7ftt oar '
Injection Welt: fi tt
0A4uWcrRc6tt3'rsr' 0droinitivMwRcincdiatitm 1 1ATlit,rGkAti�lkiEA�yl
rR a � �nat, - eavey�� �Tr�.n
G7Aiqtrr(ar stCrt tge hni Recovery' [ $tllinilti 13ttrricr 47 fit. 50 ft. SAND #2
QAgnifer lest ❑ lotmmatcr Di tioi9�e
❑Evctemcnhi TmItnology OStdksidcncc Cordrul
20:11R11.���t'r'a�tlt3faii'sieh'edit#(i#n">+'i.atieeis�f�iecessar��1R, ,
dGeodiettual(Closed Loop) ❑Tracer FRckAr TtF D rR.rt�o;cabr.iherdnrtt aw=R'n,ca r tt erba etc.
0Geodiettual eaur Dili Rettim) 00tlter JEMairt,under#21 Retlmft) 0 R. 50 ft, SANDY CLAY
fr.. fL
4.Date Welts}CompIdIed: Wet)ljD#
10-7-21 AS-6
51 Well Locath= tt IL
7-Eleven #36069 ft, ry 1
Tatoilit}'.+`O'nrtcr3vottee Facelilo•iT}�fE�plicriblol ft. ft. , s,;_••
2375 Lewisville Clemmons Rd., Clemmons, NC, 27012
Ploticol'Address.Ciq'.amdbp
Forsyth Bentonite Seal 45 to 47ft
C'fitr* Parro 10fit rk."tion 140,(PIN)
5h,i titiihtdC and.L ontritutie in tfegrecl/'minutesAcccinds or-dccititat detran 2L Certification:
(tf;ncli:f�«Id,` Liifpn ifgtdricitN)
)r W . 1 10/13/2021
stgmm .tfi fC^' v�! U.hMk e — -� 1)ats
G.Lg(art0 tlte:asell(s): oPt'T111ttltlen't or oTemporary 11A arg✓i `„ r.ri 0*1t fm''*r�",!c ' .g� x'. uT.i a�e'�:e rari nre'teaf irr-mti ,dmvcr
i v'Yk 1,9 NCAC 02f 4— Y+;V'�71,,t4.026 7 Nd fd Gvrcsvrtr�.rJ��t SwWaMs and tJ� i a
7.Ia thi-.a ncpair tb an i xiWrtn �clii 01 es" 6'r K No copy of(UT remrrr l aa•bM4 pnwhAn f rri-tfsr trril vwnrr.
Ifrrrfy`ls a ttpair,fall avr kmalm writ emmn edon brforrwrrlwt mur explobt Me nRro.re(jf the
repair UnderP21 remaifs'mi riinri or an Me biWl-of thlr forhL 23.Site di`tiyrato or additional will detaffi
You niay rise die back of this ptgi to pimlde additisD W%sletl site di:tails or t%vlt
11.tlnmtaer of�'elln aotrstrtttted: 1 construction details, Yoti i m also'auaeh addil offl,t pages if necessaly.
For+itailrlpfe 1*erkui ar'ami-rmm,rtyapJyumftt 0N1.Y with rlld.rrame°constrmtion,Y"ecm
ntom t nor form. C11II"[1f(T fA'G"fM1TCT 1 _TTONC
9.'TotalFedl:depth beloirlandsurface 50 (ft} 244L Fbr All WellK: Suhtnit this fartu Mthia 10 days of oompkiioti of welt
Frr emeNrlpJr =cPrs rfar art Rrru r fl tri err+r r(er<m +fe-:t�2(1i?mHf a�rfk7) consdirtetirin to the foltou'ing:
10.Static water lei'et below top of easing (Yti,} bii'ision of Water Re ourtti,Information Proceming Unit,
If rraerr lrsPeit rs above rdsirtg't+ +" Ib l7 Hiatt Scn ice Canter.RAICigh,1NC 27690417
t t,Borehole diamcter.8.2-9 (im) 24b.For tnimtioti Wetls;ONLY:; in addition to sending the forni to like address in
249 above. also subihit # copy, of this form within 30 days of 6r pletioo of well
12,Well vonstru—Mon method, 4.25" HSA Mostmedon to rite fo1.lo*iae:
(i.c.�ttgar.iatst}�,:iablc:'dited tpisld ctc:) .
'Dhislon of Water Resources UtWergmund Injection control P`nogrant,
FOR WATER SUPPLY WELLS ONLY: i636 Malt Serk ice Center,Raleigh.XC 27+i99-1636
13a.Yitdd(gpm) Method oftsst: 24c.For WaterSRnitly&Injection Wells:
Also subrifit one aapE'of this fierier i ithin 30 days ofcotnOlet.ionof
13b.DiAnfevilin ty°ptu Amount Amli construction to the counl_y health depa"Mintt of the courtly w1 re
conslmeted,
Form G%'-t Noah Catolim 17q=tmxn9af Emimamteti a�'VIn"Remo es-.Divisbn of Water Routes Rctiised.Augul2tal3
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