GW1-2021-07880_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD For irterml Use ONLY:
nis farmconlaet>sGd.Fw.sitigle'or m0iplc nx8s
1.WTI Contraetor:tn[atrttation:
,IA..AMATEN ZDNFS
Robert Miller FROM 'fit br�(RrPrt#�
*01 Gi�ig tdr tl3�rit4 ft. ft,
2675 ft. ft-
NC Wcll Carmsse for Ccrlifacatiou Niinrbcr 15,OUTER CASING ar in h c9iqed l"cEl OR LiNER"(Pr a 1�cable)
FROM TO DTAl IliI TH147 NE" MA'TEFTAL
SAEDACCO Inc 0 (L 15 fL 4" le, SCH-40 PVC
Cavpi ll•Noon I6jNNNER CASINGO3t'T0BM "`tbei-m'a1 tktt ed466 '
FROM 'TO DIAMETER. Tn1C"FSS MATERUL
2.Well�tpnrttuq�t'tion PetThit r* ft. ft.
f rr erlim,Cynf3rnd4le rdliv min 0--r Caunry,Soria,.Marlowe.i'reettion ew.)
rt, rt,
3.Wc11:Usc{eheel:il-di sloe}. 37.-5CRLf
-- -.. - - - - -_----- FROM,- 70 _ DtANrFTF>R StOTSFI 1 TNC7N M, MATRIUA1,
Water Supply Well:
DAgAcuhiltal DMln'Mpal/Pub is 15 ft, 25 ft, 4" in 020 SCH-40 Pvc
L7 eothenuai(fle tting/Cooii g Supply} DResidential Water Supply(sipAe) f� fta in,
Olndustrial/Cotmntcicial Mesidenteal Water'St (ft red) ]B;.:GRO[Ff ...;_•.
Two-All Two-All TO N7ATERT L 7r'N1t ACT 4EXT I MM0D&AAI0UNT
lion 3 ft. 11 fL Portland pour
ikon-ANIAterSt{ply Well: R ri
OMorl$nrin- GJft�psr
Injectlolt Well: ft. ft
13A4tui1cr Rccharsr OGrDtlndwaler ltetMtct lWon ?9.SA' bt ftA+l E1i,PA. (; lrC ihtc
rR �tf NtaT I>l11, � Rkj�1 A.T�tr�1T M�«S'ff�n
❑AlttinCr.$tGrlp ttnri ltcco�'cxy' t7$alinh'BarticR 14 It. 25 ft, Silica Sand 6/20
❑Agtrnfcr`Test O$tomua'atctbrwml�p
OEgtcrimcnial T-mImology DSrdas+die! owl ..
;tt1:�11R11.Tl�l1C-`'J,OG fatiiich bd�tHirstrila'siicei��faacccssxrti _.
13Geoilterroaal(ClostdLoop) ❑TMcee 'Tir n cRrrTro; Lvls'r;hendneo bYNf�NNICIr tt N,LtIc.
❑Geothermal cetin a1Gaoli aRealm) ®Oderf airunder#21 Reloads) 0 IL 25 (L Tan Silt
4.Date Welt(s)Complelctl 9-28-2021 Wdl D#SVE-11
Sc Well Location: fL fG
7-Eleven #36069 O- fL NON' p „�
1°ae'tlitga'O•n•nerName �acr�ii}•llylr�F�aplicnble) R, ft, ,�•� n 3'tl'¢ri _;,,
:�.Tt9r 1� 4 Sr
2375 Lewisville Clemmons Rd., Clemmons, NC, 27012 ft. r> rc ,ems c:cr<C; N
Mo-sknl"Addpss.City.and Zip 21 ItE61ARti S.
Forsyth 3' foot bentonite seal from 111to 14'
colikt' P?aM401&-M1Ir`rcdirinNo,(ptj'1')
Sh,1 tttihrdc and t tin(;itade in dcgmc;+aniP1PtcsAcc6nds nr decimal degrees; 2L Cet•ti#reataon:
tit`w�*li tl'cad;urn lllffpog is S�F��i�rti)
9/28/2021
6.Is(a ry thc-we11(s): EftrmAneat or oTemporary t sA,win Ws d.. t herelty csr
b'P1rGtr,rhe n14a!Kma(atrc)4wrarrnrrterl 1tr actixtrrkrote
irlrh`154 NCAC-02C 0100 or IJA NGAC 02C,0200 Moll Cairsrnicrlcnr Sraadarefi arncf 00i a
7.La th%a repair fb an exist p;well: Men or K No a 47P*Yor*(lid'r M-Onl li S ild rn PMI;IihN d io ItW Ii N:li RW)Irr,
df rtrfa is tr rrvair.f711 e�Par.r'rrtiitw rvc11 cErasvnrcriow drforruntdrirr mul rrplalar tlle�nrrare of rbr.repair tmdrriM remaffa:rntfran bran Me hrx[`alrhrs frirne. 23.Site ditgramor additional well details:
You":tinny use the liaclt of tfbis pall to OroAde additional%%Vfl site de ails or Well
8.11umber of wells constrttaid: 1 construction delai[�: You iaa�also attach additioiv�N pages if lr:cesssrty
For mudrlple hrk rksn or om-rtwtre mgWy irells OjVI.V MrA rhr wmr consfruedmr,y-em earn
submiftone form. .0 7i#M fAL INS16MONS
9.Total welI depth below landl surNet-, 25 (rj,d 24a, F8r At[ Well Submit this Aim it'itbiri 30 days,of completion of well
For construction t9 the tottoui,ng;
10.Static water level below top of casing N/A (D,) Dfvisi n of Water Reganrtes,tnformation Pruc"sang Unit,
If ituter Wei&above erlaf(kg'M:e r+" 160 Mait Service Center.Iialc'rhhr c�1C 27609-16 t7
11,t3orebnle diameter 10.625" (in,) 24b.Far 10mlista LVeils ONLY: In addition to sending the form.t0 the address in
24a above. also, Aft i t a copy of this form within 3330 dm•s of completion of well
12,DrelllaDnSttu-ctionmethod: 6.625" BSA Construction to tile folloAing.
(i.e.mi er. diner pasta etc.)
Dh isiuu of%later Resources.Underground tnjeciion Control Program;
FOR WATER SUPPLY WELLS ONLY: i636 Mill Se*fflee Center.Raleigh,NC27699-1636
13a:1ivid Win) Method of test: 24e.For Watrrluppl2&t "fl'on Wells:
Also submit oily copy of this f6nn within 30 daysofc�onlolei ion of
13b.tlilinfLefid"type Amount: well construction to the county li,ah:h department of the county where
constructod.
Form GW-i Romh Camlim Depb1nten9 of Emirnnnueia mid Ninon[ResaLtws-T?Nklon of ftte Rewurc`5 Res iced AtCgt 2013