__20220311 (32)

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WLLL CONSTRUCTION RECORD For Infernal Use ONLY:
` This form can be used for singk or multiple wells'
.).Well Contractor information:
t4-WATER ZONES-.
John Eiseman FROM TO DFSCRIPT1tN
Well Contractor Name
ft. ft.
ft. ft.
4439A
NC Well Com:actor Ccnificntion Router IS,OUTER CASING.(for mnhitaetd W ens)OR LINER(N an Stable)
FROM TO DIAMETER THICKNESS MATERIAL
SAEDACCO Inc 0 ft. 12 ft. 2" I In. SCH-40 PVC
Company Name ,,,16.INNER CASING ow 73iSING teeolherriral ckrtxd.003r) ''
FROM, TO DLAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. it. in
(in all appli able well permits(ix.County.&ate.Karia,we,Iree tfC1 rte.)
It. ft. In.
3.Well Use(check well use): '17:SCRH N
Water Supply Well: FROM TO DIAMETER stir SIZE I THICKNESS I AMATFRIAI.
°Agricultural °Municipal/Public 12 ft. 20Al. 2" in. 010 SCH-40 • PVC
°Geothermal(Heatingtooling Supply) (°Residential Water Supply(single) h. ft. in.
°industrial/Conmtercial °Residential Water Supply(shared) ^FROGROUT 10 s1ATFaLnL I EarPlnclMrvT METHOD.cAMOUNT
O knew ion 0 ft. 3 D. Portland I Pour
Non-Water Supply Well:
ft. n.
@Monitoring Olkccovciy .
injection Well: ft. ft.
OAquifcr'Recharge OGroundwatcrRCnrcdiation 19.SAND/GRAVEL PACK(ifmt)r(rlkabk)
FROM ' TO I MATERIAL EAIPLA('r:N ENT so:two
❑Aquifer Storage and Recovery °Salinity Harrier 10 ft. 120 ft. FILTER SAND #2
❑AgnifcrTest OStorm«atcrDrainage ft• I ft.
OEsperimcntal Technology IJSuhsictcncc Control
20.DRILLING LOG-(attach additional sheets if ncccssttrs)'
OGeothemlal(Closed Loop) °Tracer FROM TO DESCRIPTION feohr.hardacK,w(t'nxk atx.rtriln•for.Mc a
OGeothcnitaf(Flcating,C,00line Return) OOther te%plain under q21 Retuad s) 0 ft. 9 ft. Sandy clay
9 ft. 20 ft. Sandy silt i
4.Date Well(s)Completed: 1/25/22 Well in#tor-9 ft. ft.
Sa.Well Location: ft. it. MAR 1 4 2021
Faircloth Machine Shop ft. ft.
Facility/Owner Name Facility 1Dk(if applsnabk) rt. ft. .., •
2355 Farrington Point Drive SE, Winston-Salem, NC, ft. ft. r
27107 Pbyskill Address City-and Zip _. _.
21.RCMARK.S-
Forsyth Seven foot bentonite seal from 3-10'
(bratty Navel Id:nttficatiouNo.(f IN)
Sb.Latitude and longitude in degrees/minutes/seconds nr decimal degrees: 22.Certification:
(if well field,one tall0115 is suffickiat
N W ' 2/18/2022 _
5ugruturc of E.f 'is' .1 0•mile Date
6.is(are)the well(s): @Permanent or °Temporary f• c; ui <+! r` ,s -�' 'G q
It,'Signing mho coo- mf t i..e.r1 to,uttuttrd to rne©rdernee
with l54 A'CAC 02C.'x:'-,7 f^` Cla:.;;IC.0201)Well Co mfrtn-tion Standards and Ant a
7.Is this a repair to an existing well: Oyes or Kallo copy of this want m u been p';'1d d in Mr uvfl!metier,
1/thlt is a Iepnir,fill twin(noan well cMuinmlon inforinarion and explain rite nature of rlu
repair under P21 remarks.certion or an the hark of Mix form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 cotstnrction details. You may also attach additional pages if necessary.
For,nnhtplr lnlecrion or#rat-t.nri'r.eupph reeks ONLY wirlu the some consfructioir.you cast
cahmir mme fart. SUBMITTAL'INS I L)CTIONS
9.Total well depth below land surface: 20 (ft) 24a. For All Wells:. Submit dais-fora within 3(I days of completion of well
Far multiple wells list rut!depth If dl,(terent(exav pfe•3t'200'tutus 2(eIner) construction to the following:
10.Static water level below top of casing: 13 (ft.) Division of Water Resources;Information Processing Unit,
i/u nset level is above easing,due"+" 1617 Alail See ice C.cnter,Raleigh,NC 27699.1617
II.Borehole diameter:10.5" (in.) 24b.For lnieedon Welts ONLY: .1n addition to sending the form to the address in
24a above. also submit a copy of this font within 30 days of completion of well
12.Well construction method: ESA constnictiou to the following:
li.e.auger.rotary.cable.direct push.etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Ralcigh.NC 27699-1636
13a 1'ictd(on)) Method of test: 24c.For Water Supply elk Injection Wells:
Also submit one copy of this fortis within 30 days of completion of
13b.Disinfection type: Amount: _ well construction to the county health department of the county.w•herc
constnicicd..
Font OW-1 Notate Carolina Ucpenmeut of Endrotui ettd and Natural Resources-Division of Water Resoere Revised August 2013