GW1-2021-07872_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD For ratcnml Use ONTLY; 4
Uis`form can be aged for singlc'er odtift nails
1.��`�t GontrnctorI�tiartstatioti:
14:1WAT'ER ZONES
John Eisenman FROM I* bFURrlt'ItO
Well!COAmcfrn Ntartic. R.
4439A ft. ff.
NCWollCammuorCcrtifmtionNumebm 15.OUTER.CASINGI nt"stuM}t�?xr10-cns OR LV'F.RAIli "iiembk
TROM TO PIAMFTER TUFC.KNFSS MAMTAL
SAEDACCO Inc 0 fL 48 i't. 2' I �o, SCE-40 PVC
Cnff�gtra)Nna�r 16l]NNEdt.C:AM,61OIt7@BlfsliG' mtherriiattiGs`�1 i�5r
FROM TO DWIFTER I TMCKAESS I MA'TMAL
2.Welt 6ristr uction Permit ft. to, 2 11L
Liar Oftam?i mNe wrtllreinrits fig:County,Stuar.;-Variance.lift OR nw j
ft. ft,
3.WF lmsc(e ee&well psc? 77.5C,tt!t N` l!
-wster 3nitltlr°Wc11 --- ---- FROM, To oinrtrirr R lffA r5ir�► 7nrCrc i s5 MArttRiAr.
©Agricttitt7tal r•Jl4 umcipal/PubliC 48 ft= 50 ft 2" iu O10 SCH-40 PVC
❑Geothermal(Heating/Cool'in Supply) OR.esidential Water Supply(single) ft [L irs
01ndustriallContmcrCitel Oltesidtntial Water 5nppl!•(slued) 18::t;ROtif
FROM 74 MATERIAL 7?tetr'[.ACE M ENT AWMOD dt AMOUNT
❑liti brn 0 R. 45 fL Portland Tremmie
Nor-Water Supply Well:
plv oMt(1knP pltecpt f►» f1.
injection well: ft. ft
0Aqui(crRccharst Oorrotand*mcr Rcnrcd adore 9.,SA1NblC V UA YtP ti Jeable.
rtt�),Rf _ 7nr RMt. ��fPfi,.A�'itwF.VY;str;Ttt_r1
pAotiifcr StarrSC PirJ Itccr3ve p$Tldnin'13arricr 47 fe— 50 fi, SAND #2
❑Agaifce-Tcst ❑5tomm-atctMeina9e ft. ft
❑ExperimcnhilTohnofogy ❑SrGhsidcroceCardt l 2t1,:ITRiiJlli\GiOG7aitacbadttitiohalahccls7f ceeaserti`9
1:3G:oiliermal(Closed Loop) [Macer YHOINI, TO bTscRrrmoa♦nTor,aa�daer+ors;'r an u. a a�trt
❑Gcoiltemtal(Neetit Gooll r?Renrm) ®f�Ileeriea aittunder#2,t Retnatks) 0 (L 50 (L SANDY CLAY
4.Pate.Well(m)Completed 10-7-21 Wdj ID#AS-8
ft.
Sa.WMM I oeatifiint
7-Eleven #36069 ft ft. NOV
facilu1ya rrncrNafinc Fa,cuh)-mmk j'appimmc) 7
1t ft. ,
2375 Lewisville Clemmons Rd., Clemmons, NC, 27012
Pl�ticul.akddres-City—am Zip ::2 REMAIMS
Forsyth Bentonite Seal 45 to 47ft
Cdartln}` pa1tiC7-t6^r75ttc,�fii�nNc,
Sie,iattitudc and t ongitgde in dcgmshninutesAwcoinds 22.Certification:
titHplt fptlrl;rtttc i;�ttlpn&lR titi7lc#st�t}
l� W 10/13/2021
5igavai^ ' liatr
6.Is(ar l the well(s): O1?ctttrianent or ❑Temporary s k'y v ems`
�r ndi alias fro r, r ..",ir.,,� 1JY.,,y;ri�a�cr.�ace:X.�avmrfnrcttrl mi-trcx�rrlemCr
,YC:Odlk7 RI+11 C-9monfrrlt.ut srmdords and jIFnI a
7.Is this a repair to an existing n`ell: 01'es Or NNo coy n,;t 11r rnrnni tins nrrn pnn fdm ropfw ttrll mwi'm
if rhlils a repair,fill roar kwim ttW1•mwnrcvfmrbtforr ilnar ad rapfafar Me norare of dhr
repair amier#21 remrarks.ti nrtion Arran 11ae larAd of diis/'rarm 23.Site dt`9Q'om or additional well details:
You ma} d'sai back of this pale to OFOAde additional well site details or ti•ell
8.Number of wells constritcted: 1 construction details. Yottumv also ti.ltach addidonat pies if tmcessavy.
For mafrf*11tWO011 t -rrnvi-Mrtier a :r a eth ba**'LY i4rh rlar same conskrrMmr,-pm can
muNi r mar frarm. SUB(1iCl"I'AL Ib1STUC:TIONS'
9.Totalwdl.depth below land surfam 50 (ft,) 24a..Fbr All Wells: SAntit this fomi mithin 30 days of roir pktion of well
FarmA#ji r1i jellr14yof/d'c7 bil)'doIri-r�em(exmjpfe-3@2171r Omy2@fmrT congtnrctiontoOwtoltawin ;
10.Static tauter level below top of casing: (ki D,Wiision of Water Resdurtet,Information Pracesmul;Unit,
If uum level is'abdoe c big Aim•'#" 1617 slail$eniee C16ter,RAleigh,NC 27690-1617
11.Barchole diameter:8.25" (in) 24b.For lnier•HOt VFcTts ONLY:I to addition to sending the form to rite address in
24aabmt. also s0ihit a cola' of'this fortis tvitbin 3+0 days of completion of ttrell
12.Well 4mr-4mcdon otctbod,, 4.251, HSA eonstmetiori to the follouigg_
(i.e.sine.ratary,cable.dirm*k ctc.l
Division of Water Resources;Underovoind Injeclfon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cfenter,Raleigh,NC 27A99-1636
13a•Yield(gpm) INIctbod of test Zbc For, area SnCply�Yc Inleetfxn Wctts:
Also submit one copf of this foriit ttithin,30 days of completion of
13h.diatlnfiriCntn t 25<. Amount: well eonslnictepn to the coemty health dcgadment of the Ecnrnly wlem,
constructed.
Fenn GW-t North Carolina Evp, namrofEmimmmemandNtart"Resoums-Di-tisionof\YarcrResoum Revised AugM2013