GW1-2021-02436_Well Construction - GW1_20210615

WELL CONSTRUCTION RECORD P�lttrraulllsctlNLY:
This rom can be rind for afttc of natiple"Ills
1.well Ctintrwetor tntarmsttoo:
Stefan Smith nmmu,11Qv
V'dtCatiftCW Kong na- n. ft.
3576A
NCSitcllComtscrotCcnif6catioaNnmber J1J� 1 `OL� n11 S.DtTtFR. !N(34 atnYMiasrnlinvtata QR'LlM INNcaYite
cS�rt��J FROM TO I mAMPTER T19:CIKYES4 MATERIAL
SAEDACCO Inctvp ll
prc��+ n 0 fL 10 fL 1" 10. SCa-40 PVC
Cafl1C15ig @dbaiCttA OIOR hB
FROM I TO DiN FTBR I TnI KN'ESS MATERIAL
2.W41 ca stntcrion Permit#: n. I to.
Liu ail qppNmNv NrtlpenwfrW(i e.Camty.Saar,Variance.lqw)at rrr)
ft: n.
3.Wdl-Usc(ebedt well use):
Water Supply wcDl: FNOM To _ 010 XTrR. r �,> T1n41prIL'�S MATRRIAL
OAgr ulturll I�2vllmicip61li tblic 10 ft. 20 1" l� O10 SCH-40 PVC
OGeothemtal(Heatingfiooling Supply) OResldeidal Rater Supply(single} n. ft.
�
ClMdusttial(ConvneMal DResidential Water Supply(shared) iA.Ltit UT,
FROM I TO MATERML EMPUCT,MINTMEritOD t£AMIDM,
oftrigstion ft. (L
Non-Water Supply Well: ft. fit.
Mmonitoli l7Recmt
tojection well:
DAguifer`Rccharge C1Groundwater ftmo Nation
tAT89 4 RMP1.n ,n;VTMETH o'
OAgnifer:SttmlgC aid tt ►v C1SatinityUamct 8 ft. 20 ft. FILTER SAND #2
DAggitici Test Ustvmmatcr omiin ayc- ft. ft.
DEXPCrimental Toclmotogy CIStfbsiftmc Control
.rDtRtl9at<t's-J;Oii rrM�BdiiiontrlShecti4faieces;an
Meothennal(Closed Loop) OTraar FRO14 TO officRrvtaov r•.r+o aoWlnkR rRraiir"i
oGtothermal ea" 'Cooll Rewm) OOdter in under 921Retnarks) 1 0 ft. 10 fL Sandy silt
10 ft. 12 n, Silty,clay
4.DateWett(OCompheted: 5/25/21 WellID#SB-2 12 n. 16 n, Silt
Sa.Well lnratiim: 16 A 20 fL Clay
Reynolds. Commons Shopping Center 4. n.
Poeilit#M%,wrNatae facffi!-1D8(irappiiubie) M ft.
3508-3576 Yadkinville Road, Winston Salem, NC, 27106 n, ft.
Plotiml`Addrsss City:and Zip 2t t
Forsyth Temporary well for groundwater grab sample
fnntay Pateet ldtrH;ikrtioallo�,(PTh)
Sb.Latitude and t ongttadc in dcgm vJminutcsts=nds or decimal de grew. 22, i}-cratinn:
(if"cull frdtd.wie l rsnna stdPit;rrn)
36.153119 N 80.314347 W 6/7/2021
A
4Mfa1W—*ZHc0vt--t- Dare
6.15(are)1he wdI(s): OPettmaneat or ZTemporary Bs•signing Air f-M 1 heretl t'ertlfy their W. fiiz)wds(r i eoftrnwW&a eortiar"
n a)15A NC4C.02C.01W o►15A NCAC(C.02AP 1*11 Canumarfon Sroadards end 4w a
7.Lb tins a repair to an existing well: flY�s or W No copy of ihir reTM-dlans brew tmm/drd toile aril okvwr.
If INS h 0 rfWdr.,fit ONt 4001M WC41 emurrucvfan WamaurrMR mul capfei+r thr+ttrnire Of dW
reryuir meder*?1 nmardLv.nWim aran the bark of this frrrdi 23.Site diagram or additional well defaits:
You may use the'bacb'af this page to ptmidie additional well site details or well
S.Nmubtrefwellsconstrncted: 1 eonstroctiondeWls. You may also tutachaddiflonatpages f> saty.
For nt+driple IRIff"or mm-offerer App)y kWh ONLY,446 rhr Wane coirstru don,you can
as w1mcfne+u $UBMITTAI•.INSMj43'lOt3S
9.Tfotalvdt depth below lend surfacc 20 (n,) 24a. Phr AU Wells- Submit this fonts M.thin 30 dm s of eotnpMion of wttl
fori"IiNeicrtlsUitolldtt*rfldi,Ifierrnr(e We-3,0200'ara1;7 OV) CStnshtmtionto the follcmins:
10.St de water IMTj bdoW top of rasing: 17 ({t,) t)ivislon of Water Rrsdurees,tnrormatipn Processing Unit.
If�rlrrtkrr<t lsetrove cwshrg.� "�" 161�hfaii$cn�oc tkntcr,RWileipfi.�C 27649-D6f7
I1.Borehole diameter:2.25" (in) 24b.For inie Wan Wal1R ONi Y In addlition to sending the form to tilt address in
24a above.also submit a oopy of i�tttis form within 30 days of compietion of well
12.Urell eongr7redah oldbod:DPT co istnictton to the roll A lu�p:
(i.e.saga..,art".cable ditcd push etc:) ftislon of Water Resources;t Underground Injection Contr+oi Progeltm,
FOR WATER SUPPLY WIEL S ONLY: 1636 iklall Semite Center,Rdd9b,NC 2 76"4636
24c13a.Yield Qtpm) Method of test: .For WattrSapplt a4c hn�edlon Weft
Also submit one espy of this fodn within 30 days of completion of
13b.abourmilon type:, Amount: mrclh construction to the county heal b dcpaM= of the county where
constricted.
Farm G%V-t North Camllna Dgwtmcaiof Emimnnmd and Naturist Raomocs-D3ttiai000fQVatcrRezirM Rcsiscd AtC St2013