GW1-2021-07869_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD For lIftrMl Use OAY:
'Mb rvrm coin W asodAby sink or mallipic wetis
1.Well ContractotInformitlon:
,la;_lVAAU1C ZONMS
Robert Miller FROM UJI IPF$CftIPrft),N
2675 ft. fL
NC Well Comm6tor CcrIjF=tI6tiNIunbcT 15.OUTER CAS -'(Idr4m.'HI4i4ed*vrks)�il,,-, ,Kablel,
FROM TO DIAMFTER Tli-Y=ISIItATER TAI,
SAEDACCO Inc 0 (L 48 ft, 121, fin, I SCH-40 PVC
Company Name JOANINM i ASIN0,03f 7MBING"di tiit eflakid4MO)
FROM '70 I)LOWTER, TMCKWESS AtIOr"4L
2.rWejj_C(i"5
IjV 4,11'rRiiirable wed PM. Mtr,oa..Coirmy.'stwo.;-Varfame.If#kdan ncj
3.VMI-Ose(cbcdc I wd I I Oscl.
Water sapply WeIll.. vm%l_
48 ff� 50 A, 21, 016 SCH-40 PVC
ONIumcipaMiblic
0(iocithenw.1(Hicitingtooting Supply) dResidendal Water Suppb,(single)
Olactustrial/Cornniercill Olkesiftifial Water:Su" -(sba red) J,
FROM To 'MATERML MPIACENIEW AMMOD&AMOUNT
oh-figgtiOn 0 R. 44 (L Portland trimi
Non-Mlater Supply Welt:
k k
Injection Welt: M (L
OAqykkr kccfiam�e 0(jFMjAdVOajCF RCIRCdiqI6QTI
IA'll
OA4 fcr- Oragc
tif' $t ­fin4kCca'" r l__MAT4R I , i
' 0 l3arric' 47 rt, 50 ft, ISili6a Sand 120/30
OAqnrier"Tcst liTairfinz It. It.
Mvcrimcnsal MxAnotogy O$Idwdcncc coniml
i1c,willental(closed Loop) OTracet FROM: 'T,0
EIGoothernial{FfnfiBa2- ofiN Recruit} ®tither{v ain under#21 R=adw 0 (L 50 (L SANDY CLAY
ft.,
4.Date Will(s)Completed: 9-29-2021 Wdl ID#AS-11
IL IL
S&MIL411 LAicathin ZVI
7-Eleven #36069
FactftyAO wncrNarw Facait,wo(irappitasic)
_3;,G
2375 Lewisville Clemmons Rd., Clemmons, NC, 27012
Pkiicifll M ir,skid end Zip _TL_WCMAUKS'
Forsyth I Three feet bentonite Seal from 4411to 471
catilk Nteo JaLv"..64wan Na,(PINI )
56,1,iM6dc anal Ln'nkitudcindegrccOninutcsIscco*ndso-rdecifnIA' c
Idc- ,
fIfm 0411P44;om 60otig gres: 22.Cettil'ication:
_N —W 9/28/2021
Sign of Ii&w, Date
6.Is(att)the well(g)- oPerinanent or OTemporary
Hy signing.this fiArw,I hereby creftfy ihaf the mwIlf.q mvx f werr)evins-inwied hrl4tvaidmee
ivhl RM NCAC 02C.0100 dy JJA KeAC 02C;0209 Well Cojmrierlair SraaddnU and 4jal a
7.is this a re Pair to an.tAviing welk OVes' fir KNo ierHfA_VjirrI
if 16(sIP 0 mdexplabi the owrore of Me
f&b"l-"pu'prm, 23,Site di*am,or additional will demitc
You'May-use the back of this page to'llrokiide addilioiMl,%Tfl site details or well
8.Number of wells construrted: 1 Lxxtisituctiondetiaks. You.MAY also attach.addiffi6hat page's if amess I a ty.
For otwldpre Ir Wrkm or noj-mjrarxaVtplyttylfs ONLY 0A rhr xrme *Ps&Mlw,YON can
RAkfit star fnmr. SUBN=AL'MIUCTIONS
9.Total well depth below land surface.. 50 24% For All Welk Submit this Ibnh milhin 10 d;syt of obtapkii6n of well
For olnif0ple leeffs'Ust ofleepths f1differens tex0i00-MM'Ond 2@ 1 M) constniction to Ilk foitoning;
10.Static water level below top ofrasiug: A) Division of Water Ittionreti,Infitrakationprocelsing,Unit,
Ifleater MV04&Ob6pe cddkg,&V 1611 Mait Service 6nteri Ralco,Me,21609-1 617
11.Borehole dianickv.8.25"
(iM) 241b.For Iniaft We is 15 ONLY: 1ln addition to sending the form to like address in
243 abdii also submit a copy of Ns forni within 30 dm,g of conipletion of well
WelleopstrPcOon method,- 4.25" HSA COJISIM60H to tlkt iOIIOA*iIIJ2_:
Division of Water Resource'.Underground Injeciloll Control Program,
FOR WATER SUPPLY WELLS ONLY- 1636 Mail Service tenler.Raleiali.N. C'274%0436
13a.Yield(gpn) MONO-of test 14c.For%Vmtcr Supply air InjectIoff Welh-
i ,
Also subthit one copy of this f6r[III within 30,daysot.conipletionof
13b.Dkinfectliju t)-pe. Amount: vmil constniction to the cainay llicalth d*rIn3cM of the county where
constmctcd.
ParmGW4 Nodh Orolina D*rtmemi io[Emrimnmat and Nnniml Resources-Dikklon of Walcji�ltmwcm RcOised AuguA 20 1.1