GW1-2021-07881_Well Construction - GW1_20211102

i
WELL CONSTRUMON DECOR Far rntcnwl Use ONLY:
Tins rat ricati beu_ccd.rw¢itieleor mWtipk hells
1.Well:GnntractorItforinatioo:
1 ATE
Robert Miller FROM Tit ba54ftlpirn}S
tWf Cor4nti7t t�;rnie rt.. rt. i
rt. rL
2675
NCWeIICOritritctorlCenif»calionNruibeT 15 0[1TERCA�f51G' nrinnMke�medpeFls ORL.1NERfif4 Trcabk
FROI•r TO PTA'MFTEft TIIiCi MM 31AIXRTAU
SAEDACCO Inc 0 ft, 48 fL 2" im. SCH-40 PVC
Comp.my N;4wc 16 11!f,WElst i�ASIfHG OR"C1161TfG hei�tl3i tkil d 1t7ti
FROM TO DU1fETER.. THICKM95 MATERIAL
2.Wch Oinsiruction 1'ertrfit#. ft. rt. 11L
u a oil rr�?,46te wrtl Hermit(P_r,.Cm,.swse,trnrinrtee,Tieabart eVc.j
3.Well use ok4c N%til use):
Water Supply Well: FROM TO 'PtAl►r MI V10TCI?A ir"I T(Nh�'s 1MAT9111M,
I�Agtieulnlrtl I Mtti+ticiputltFt(b6i> 48 fr. 50 ft 2" in. .616 SCH-46 PVC
❑Geothermal(Heatinooli St DR.esidential Water Su ft, (L in
ItA� �Supply)� tmh'(sinLJe)
et
❑ItrdustfialFConiRtercial 01tesideatial Wiite6 Stlprpty'(S1YIr€d) A CROUFtiOAt 70 MATERML HRtP[.ACES LNT AWMOD&MOUNT
❑lrri tion 0 R. .44 fL Portland trimi
Non-Water Supply Well:
❑Ivtogtifterin ❑ coax R, ri.
Injects Well: b• tL
0A4ukkrRcchar& OdirouhdwatcrRetncdiatian i§:S.ANbiL�R.►i�E1 FACt►fi? tiFsrh ),-
rR�;tt � tn7'lktnr. t;�iPi,.Af°i�►n,�t hvt:T t�7p
gA�ni(cr Stortsc artd Rt cn t r}' _5,11inin )3grtic(
47 (t. 50 ft. Silica Sand 20/30
0Agtiit'cr"C9 173$ornm'atcr i)ta®.`l
tt. ft.
ge
❑E,TcrimcntA Tcchnq�. ❑Ubsidence Condrol _ ,
Itf;VRJlAJKGLOG' tiach5tdrtiiiisriatsticeis faeecesssr
❑ eodgmial(Closed Loop) 114031, TO PESCRrtP ON oalor.ItAMneo x F4 t+,ca tv d etc t!c
❑Goodtettrial(Bestir 2glt Reim) ®Oilier f. air under#21.Rematks) 0 ft. 50 fL SANDY CLAY
n. rL
4.Date Wrlt(s)Completed. 9-29-2021 Well yD#AS-10 rl
t i
Sa.N4..11 Ltication: (L rt. n.
AA
7-Eleven #36069 f. ft �+ # JLV
Rw lityi0n•rtcrNnnts Facoh)•w#(i€wplictrble)
ft. h. rEr
2375 Lewisville Clemmons Rd., Clemmons, NC, 27012
111 st citl Addmss City.nndZip 2L•y C_AtA7tk'S`
Forsyth Three feet bentonite Seal from 441to 47'
lei mo W111 r`oulion No,(FIN)
$b.1,4,0.104c anil,Longitudc in,dcgrecs/rninutWsccn-ids or decitnal degrecs; 22,Ccdtifiratittn:
Orme11(rald rtttc LitPlpt lr gtdf3cienl)
9/28/2021
Sigminic of {� Date
6.iS(are;the tSell(ti): -xPe`rmanent or o'Temporary +r nin 1fr;$jb%r.M 1 lrereky cer' rliat the Rmll(1)my 6s-ere)fxR emceed by tMYorAmce
,vl*/kl NCAC 02C.0100 or 15A NGAC rr2C.C1;tai) and dwl a
7.Ic this a repair to an ietirr kr4 n'elli ❑locc or M Nn arpic�{rfi is rccanrrl lxres d*emr(ti�rltdrtd r!r atie atclt t+rvner,
11Ws`is4 r.Jiff omelrnrihw well(v,v,ernoion Arlorraw4vi sin.$rxpkhi the ruxare(,,(rite reMir ttrrdertt2l rcma&vxErbz m or an the brxrt of ttis form. 23.Site diwam or additional%vd]detalts:
You ntiay use ilia back of this pale'to'ofovide additional uvfl site details or is'elt
8.Number of wells constructed: 1 construction deiaits. You irav also attach addili'sa pages if necessary.
Far malfi*irrj vrk,n uv-am-miree r4Wy ivells ONLY b-frrh the strose catrstradIatr,orw can
submit are form. S UBbfITTA L 1NST[tCTfONS
9.Total well depth below land surfiate: 50 {IY,) 2U Fpr Alt Wilk. 5ubndt !leis fo rni i%ilhin 3[i.doys of completion of well
Far m#lato r ivells list ai'l4fePfin tf.(1Wr',',tx Oxm ipte-J@2011`an f 2@ AV) cimstmptien to tree"10,% ngr:
10.Static water level below top of casing: (tt,) Division of Water Rt9qurt6i,InfitirmAtion FrucessAng Unit,
tf riven Merl L above wsinX&m"+" 160 Alait Service' Raleigh.NC`21699-1617
11..Burchole diameter:8.25" (poi) 24b.For LqjMfio VPelly ONLY: 'ln addition to sending the form to the address in
24a abm'e. also sitbthit a coMr of This form within ,".tl dat•s of completion of%Melt
12.Wdl t pntstxttctirin t bod: 4.25" HSA constnrction to the following_
(I.e.su er.mines•,cable.hirer posh etc.)
DhIsion of Water Resources.Vaderground tnjeeit(m Contrail Prograltt,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Gettter.Raleigh,NC 27699-1436
t3v Yf d(gp►m) Method of test: 24�For Water Supply A ini"' Wells:
Also subinit one copy of this forth Within 30 days of completion of
131i.bisinftxtutn h7tct Amonnt avctl consfniction to the eatmty 6 h de rtment of the crnmty wham
enrtstrrrcfod.
Farm GW-I North Carolina Dc=nb nt of Emfionnima and Nrinimt Resources-DI-diinn of 1Vater Resotrcet Revised August 2013