GW1-2021-07879_Well Construction - GW1_20211102

i
WELL CONSTRUCTION RECORD for IiYenalElseONLY:
' W's rurm can be used for ftic or rnrdtipk wclIs
1.Well Contractor.hitaramlon:
14.*-ATE*?.ONFS .'
John Eisenman rR01" TO I t►KSCt;tMON
w`cilGtao4rtdcrNSnt� ft. ft.
4439A
NC Well Commetar Ccriffi Lion Munba 15,OUTER: LJNFRJ Ta fkiIbk
FROM I.TO ntWETER: TrrrC•K"M MAIMAL
SAEDACCO Inc 0 ft 47 h 2" so, SCH-40 PVC
Cnoppary Naair UANNEdt(.K.'Slbt'O`OR 7tlB1M11G' `t ii6�t oa3l fetctla+fi
FROH TO I MWETER ITHICKNESS NrAMML
2c Wtlt jn5tmOion pmffit# ft. ft. Wirt.
Ija oil aijv'lirall.6k iad firAWIr,ox.G'nirm v; .m:)
3. dl
Water Supply Well: FRO)'" ._ .TO I ntAt►FIrsit I SL.OTSIM I "ICICNT Ss I MArRIMAt,
DAgikulditat 47 fr, 49 rt 2" In Ai6 SCH-46 PVC
D+Geothennat(Heating,NCooling Suppiyi 0R.esidential Water 5upplj'(singte) rt.j ft.
Dindasfitall(Ceamhieicial DResidential Wttteq Suppk,(simted) VC., Rt71fT.I-,:.-".'—,
PROt! 'Id MATERIAL I nfK ACEMLNT hIrMOD d MOUNT
D1rti Rtion 0 ft. 44 fL Portland Tremmie
Nan-Water Supply Will:
[3Monitorin gltccptc ft, fL
Injection Well:
13Agn0krl2c63,rSi CGrolarulst;lter Rcowdi.10on 7k,'SAND_ Y_EU 1►_ ,d3
- ..,.. .FROM TO I SAY _rAt, kfP3 A .�_F��7i 1tit 11
gAq Ijcr'Sto*8w RcCayt, g5aliniW Cr 46 ITr. 50 fi, sAND, #2
[Mgjikt'cr Tcst om C1$tm�tct bnt'HagC ft.. ft.
t7 pextmenlal Tmirnplogy Cotnrol -
DGeoditmttti'_ Closed Loop) O7iacet $t1:;1?RIl t ti1G1 dG'dattaeh':ladlti(tnul ON(,a�orfeccc33nr� ,:.
F170;1r- TC3 11fi5GRrA'Ti0i1 cak�r. tr dr#iatir,)`
❑GOofltennai tFleafit olli a Retunt} ®Otl►er(, ain under ff etmaft) 0 fL 50 M SANDY CLAY
R. fL
4.Date Wel(s)Qnlpleted: 10-7-21 WdI ID#AS-13
Sa:Well Lricathan:
7-Eleven #36069 ft,
P letl',d 'ncrNtnttc Facilh)-M#6tppplimblc) IVU
2375 Lewisville Clemons Rd., Clemons, NC, 27012
PID-ticn]Addicss OF.m dZip ;21.ttltttA7tt:S;. tr:
Forsyth Bentonite Seal 44 to 46ft
Cot,u ' Nrtl Will t4cvion Tlo,(PI-NI)
Ste,X;titrttrtic an 1 Lnnt itttdc in dcgrmIminuta/scCnHds ar d+ impl t>cg► 22.Ccitit'ec taoti:
(Itxlt faeld;arm I;itMangdr trefriCic"r�1)
N W y � yY„r 10/13/2021
S�gnatnrc of "T�'U�e^,�•--- Daic
6.Is(arcl dte:sce0(s}: jyrianent or oTemporara
. �'ar�arrti,�rl�at.,lmugr. rr,r(u;h,�`uc ..,,,:,,,Ku^l+.e:K,.x>arrrrrerer!'1rr.ma+:rarJtratr
umv 1.%A NCAG D2C Y 4w;de:tadt W4!11 L'omgVocrimt SMrzdero4s and Oki a
7.11athL%Itneltgirt6aneiiistin#wells c71es pr KNo cclir2frlaf record 6#r darnprorirdiWrnjhrrrrrimener,
JjrhJs h a rrpWr,fill our,trwita iMl em wnwHon br/gr6orion ar d raploh rhe,urrore of rk
repair tamter-P-11 23.Site diagram for additinal well details,
YOU.niay itse.11iitk ilkk of;this obe to groAde additional%V11 site 4eta6 or u'elI
ti.Num aer of yells constrovied: 1 comstruction details. You may alsositlacti add3tionat 1 Ses if ttecessatt#.
For nra drde le;jeeAwi or nnvq-xxrer nqWy itWh ONLY§4rh the srrelc cortstrmetfim,Y"tmr
surmintImeform. St]Bmr PALiNsTtItTIONS
9.Total well depth below-lAnd atrraoe: 49 (fr.)' 24a. Fbr All Wells- Submit this`:forest'within 30 d tvs of compllctiott of welt
£or,rceilrr 16 adlsllsr aril t/rgrhr edorm-4)(ext A0fe-J 20..Q`chid?@ddJ ) constimmi9n to the foRsming"
10.Static water level below top of casing: (ft.) Division of water Reim reel,information Prneessing Unit,
ljwdieF Wel h andvi mdhg,km"+" 1617 mail Service Canter,'k:ileiglr,NC 216"-1617
111.Bgrebole diameter:8.25" (in) 24b.fir intertiod M.Is ONLY: :In addition to sending the fomt to the addRW in
244 abiwe. also submit a copy of this form within 10 dm,g of cunipletion of uril
12,Wdl conontWon Method, 4.25" HSA cvnstniction toilre follow ne.
(i.e.sager.io M'.'46W.dimd pmfh..ctc:)
Division of Water Reno rc6 Mider0olind Injitilon Control P`rograri►,
FOR WATER SUPPLY WELLS ONLY:` t636&fail Se.twice Center.Raleigh.NiG27699-1630
13a add(tti►nt) Method of test• 24c Par W ester Sappy Kr tnlcct� y1 n 'ciRa:
Also subnut otr6 C*,of this fnn11 within,_0 day�sof=contpletiott.of
13h.DiAnfteliitn.f'pe: Amount mTH.com 4niction to the conrrt_y health d4ndum d of the cmrnly w Wm
constructed.
Form C,1Ar-L Nojib Camlins Dep:rdtrmi of Emim uncnt aid Namara Resources-Division of Arate Resotrt m Reviscd August 2913