GW1-2021-07870_Well Construction - GW1_20211102

RIELL CONSTRUCTION RECORD' For irknuNl Use ONLY:
This mconbcusud•ror3itigtcorm�tipftwells
1.Nell Contractof.Iftat�tatlan: '
14:WATER ZONLS
Robert Miller FROM T(r Dr ('tuPt10\
WOO Cai4rrttrxr Mar-C•
2675
NC Well Com 6tor Certifietition Number 15..OUTER CASING br iirjifti4-2kil oxFls`OR I.1NEltA14 busk •
FROM TO PUMETER T"ICKINF.S5 MATERTAL
SAEDACCO Inc 0 ft, 48 tL 2" ;u, SCH-40 PVC
Cdowfl-Nmt- 16.<1NNEdt Ci1SfNGO3t T- UBW0,, " hbrVnM&0 daari
FROM Tfl DWILTER. MICKNESS AtAIERLAL
3,Wrlt Cr)nsirlictenn Pcii�nat#: ft. tt.
frsroflmIlir,'me wdllwn*ft Cr•:+r:Caumy,Swo,.mariairce.Iritecbraq,ev.j
it, fb
tt'atcr Supply Well: ---- --- --- FRO,%3, $10TSM, TNrMM-4 I MATFRIA;
CItl�rieitIm-11il 0Mt1liitiipaVPttbliC 48 ft: 50 ft. 21, in. old SCH-46 PVC
Mvothennat(�satint1�ootin Supply} ❑Resdntal Water SuPlh'(single)C Mdust�FCon�tercial ❑Residential Water Stippb-(shared) 3A�:tiROUT• 1='• � ._
FROM Tfl IAL 1rt►tPIACV7►1Tn'�IT MGD—&&AAIOL'N-I'L
❑1ni' MATER
ation 0 tt. 44 tt,. Portland trimi
ikon:Wakr Supply Well:
❑monitorin ORmavcTy
Injection Welt: rt tt
ClAgtrkferRcchairge CIC;rrntttilticrltetrtextiataon t4 SANb}G 17E�ITAttA: t;cabk
PROM . AT# MI., ftAfi�f ACY�Mti1.� Ai T F r iplf
❑AgtriPcr.$tcrigL,c il"d Pcior ' 01�afinit,M rti 47 ft. 50 fl, Silica Sand 20/30
❑AgWrfcr'fcst ❑Stvmm atcr 1)hti1iiez
13ETcrimcntal T-mbnoteg y ❑Srd 53dCacc Control
1G.`,f"A''ti'LfJG taftlaeh h difi(iit'n�l 3hcel t recct�snix =w,
❑GeodiernW(Closed Loop) 133Yacer .FROM TtF D SRrPrlu, c br.handncrt inil'nMr h d stri�iic
❑Gfethentaal(Reath g olit a Return) ®Outer jt ain under 921 Retuaft) 0 (L 50 tt, SANDY CLAY
R. fL
4.Date We lM Completed 9-30-2021 VVdjjlD#AS-18
&L Well_blenf ow. ft. tt.
7-Eleven #36069 ft. to. Rn�Y;
Faci1Ry)07n,nerNn= AcIityIDN(if applieriblc)
2375 Lewisville Clemmons Rd., Clemmons, NC, 27012 tt, ti • 4 G"'1:;
Mtkul,?litdressCiti'.MdZip :3t:REhtATttiS:, ' i;
Forsyth Three feet bentonite Seal from 441to 47'
Couttb' t� Ca I¢.ritiriC,�tifi7 Np,(,I•76�1)
Bh,L40.hrdc and j.r ngitudc in(IcgrushninatcOwconds or decimal OCOUr t 2! Cet-ifieation•
(iftis,.*1t ticld,��L•�'Ip[5g is grctl3e#erdl
T W `/ 9/28/2021
Sign3tn f of. n ti ' � Date
6.Is(area the<well(s): -EPtrmaneint or DTemporata' -�
k signing 1fffPj7w 1 hereht•rer ,p 1jai,Nu nu111's)rarer f�eerq trinrnnieted ur.d �unrArta7e
iaW 1€A NCAC A2C'.01 M or,1 Svt.NCAC r7;rC,Ua't?t7 N'i rf Gaarsrrrecrlcrrt Srarartdr c crnrr rdxrr a
�.Is tttie repairfo an taii4tia tr'elli OVeai or KNu coy of this reconf tint firma prmirfed ro asr aril{+wnrr,
ff drla lzn rcwtr; fl avr drfii rw 7wxt!c�r>axrrn rim 1r11?rQWikWt Md rhpialar The norare of rAr
reMiT WWrr S21 rrrerifl s:strviM dr nvt rhr&Kk of ttrir fauna 23.Site d[Sj!t'ilni or additional well details:
Yea►blap use&back of this page,to pftaAde additional well site details or"Vi ell
8.1\umbe of wells contit'ticted: 1 eonstmetiott details. YOU Ina,"also attach addido'rat pages if t►:ecessaly.
For murdfrfelrJ tnjeer4m or pall-nufte A4pplr trelts ONLY veltn rhea me—eojuVadimr,yaw tart ;
AuNj aar farm: S:T11'AtIT'PA ,.1NST T-.TIONS
9.Total welI dcptli bed land stlrfatc 50 (fy,)' 24%.Fbr All %liK S ibntit: tWs fonit mitbid 30 tlse's of comptedon of tMt
For MdhiAfrwettrti`srcrllif ftffdwererit(eymore•3@200'owBye'[M?) cdnStnrGtiOn4)1he1otlatving;
10.Statle.water level below top of casing: (ly,) Di4gion of Water Regiourtes,Information Protetsing Unit?
11foalef km Isabrive eaa(ttg "a" 1617 111a'ct Scr1iee Cenier,Rolcteli?IYC'27b�^)-1417
t i,BnrCboM tlismctcr 8.25" 00 24b.For 1nkrtioo We11s ONLY: :in addition to sending the form to the address in
24a above, also stibmit a COVA! of this form within 30 dm's of coolpletidu of well
13,W'cll C0MtrnCtion rrtethnd, 4.25" BSA eotistiuctiorl to the.foll0MILe:
(i.e.su�tr.ralo>}';:onble:i1i>e�Vista etc:)
Division of!Water Resourees.tedftroond Injection Control Pivtgmin,
FOR WATER SUPPLY SWELLS ONLY:` 1636 AtA Service Cetiler.Raleiplt,NC i7t"-1636
13a.yield(WM) 11'C010A of test- 24c.For Watc r Supply&1fticot n W'c11s:
Also subMit one copy of this fund within 30 days of completion of
13b.Dkinfc c*nn hrpe. Arnouot. AVC11 constniction to the cmmty het itb il*,dMent of the C-Minh,wb=,
constructed.
Farm GW-t North Camlim Cttgwtnmi of Emirowwat and yams)Refouroes-Division ofVlratcrlt6oti xs Re0scd August 2013_