GW1-2022-05905_Well Construction - GW1_20220627

WELL CONS'TRUC."nON RECORD ForltaarjkdVwON1_S':
Fitt3 Canncan�etsc.d Car sin(ticar tnteltip3�vtslts '
1.Well Contractor Infenuadon:
11,t%ti%3CII bI
John Eisenttaan FROM rie DFSrrttt rl(iv
W01 Coro.mciot Ra tte (i. fi,
4439-A f6 (t
NC Well CoittraaarEcnl6cstionNimbcr fS&_O TPliCilSI'mfrarrtiitti-ra evHsQti'Gf*flilb/ifa ticablel
o 05t I To Ouvw Ill VATt AL1t
SAEDACCO Inc 0 IL 70 (i. 6+' in. SCH-40 PVC
O,ugrtay Nmiw l&INNEftG'A.fil]JORY11t1114iG4, llur fl
MONI TO I OVOIRTOR I THICKtipSS I 51ATEl"AL
2,Well Construction Permit#: 0 (t. 90 ft, 2" 6r. SCH-40 PVC
isister!{aterficrvP�rrsr.�ijaenmirsfi.o.�c�unts�S:Q,r.t-arj.srrx,lrj�A't�rani - ^�-� ��� -
3.14'dl Ilse(check well stic): z�-Sf>R1iElY
FROM TO ntAMIXTr;ta 5LOTSI . TOICK EW t MATPUTA1.
'Water finp�dy WWI. ,
OAL"Rimltural ONlunicip LTublic 85 ff. 90 ft. 2" ta, 010 SCH-40 PVC
OGrotherrtaai Orle lull-MPCooling ;tlpplu} GJli idettiiral%vain supply(Sincip) ft. ft.
131ndasaial/Comoicrcial ORgsidriltial Water Supply(slcirJ) �o NOIIT Ttr v1 rTLELttI t L3iPLtCE�1)SiT'iEitlOD�A�fOtrA T`i
Ellni atinu 25 (t- 78 ft. 30% BentonAe Grout Tremie
Non-%rater Supply'Well, F19�.
ft. 25 (L Portland CetIteat Tremie
a> ooltmini; ORccav r}
ittjecttou Well: _ ft. ft.
�)�tquifer Rcchirge �iC3fotil dwiatcr Ctclucdialion ShNllifitL11+E1 PACKI:a ii:ylilcl
CiAquifcr Wragc atli Rcrovctg ❑.Salinity Barrio t 6 �1 TO NArFnF LI. tntYi kt t tti.�T SiF7Nt)n;
82 ff. 90 fi: Sand #2
1+i.4glyif4r7�t 175torinautcrDrain,�mc � fr ft.
Ol xp.-Iimental TeOttolvegy OSubsidcnce['outml
y43eR1l:i�It�t;'f:Uirftttlact�at}elitieai�tsf�cefsiE' n?
OQbfltennal(Closed Loup) ❑Trat:et 1 FROM Tit DCyCREt'TtOltt�br.lntrAa�n.nuiSrnaha.fx,�iptarer3t.1 ~'7
OGcotftent l sFleatine:+Cabliaa Retuntl L70iheg � let wuier i�1 liewtiel s) 0 it. " 0.5 rt. Concrete
0.5 It, 90 (t. Lt. Brown to Brown Moist to Wet SILT ab SAND
4.Date Well(s)Complej d; 5/23/2022 %V•dI ID#TW-2
ft, (t. '
So.W i4l Location:
Speeway 6926
F3cnitti•±Ctt%mrNamc Fa.ility IDm ti€appltiblol2022
546 E. Sprague Street, Winston-Salem, NC, 27107 rt, tt
Plr,:s'ical AddmssL Cir},and Zip .21 1l1 tri+itttr$ �-�°"
Forsyth Hydrated bentonite seal from 78-U,1 '"t-:'
(ittini? P=er idottirrtaaimi No.(PIN) i
ab.Latitude anti Longitude in degi'ccslminutcslseconds or decimal degrees: 22.Ccitillcatilm:
4Jf%%dlt'p:tr1, 0li4i:sq}
N W _ _ a Fr
_ 6 2 2022
bale
6.1s(area the weft(*): OPetmiokertt or OTemporary
f1r 349nb,g:iu,(n,r, �•: 'a rf�,t�Ji'a�'�'';�:,,rr.:...;�-!zwrtrtrarrreat fr.,fu:•�asL'2�tt�
Xis,::tt:,U'nip'elfCursmaimS(ooianisaotdfivta
7.L%thiefa repair toanrmkingwell, OY4� or KNo s,.pyre`diJsrr+rnxdha:si�4rttrr,t,7!ea�rr>af+rrr:rr,�+rare•
If zt,•la tt r?rep"Fir.fiff oil xr.rnrv,terif+r:zstrari:tic�o d,r,,{ip7twt;,:n ar,t e pkaia rt,tr rtraure of rfor
rrra:ir andfr 01 nmjurkv srraimi or en Me bete..of rGbe ffor,ac 23.Site dhigranl or addithmal ivell details:
You Wray use 11*Ila&of this page to proridv additlowd vigil Site details or well
S.Number of wells constructed: 1 construction details. You may also attach ailditionat vagvs if necessary.
Fur mt$tiptt iojeefitwi<*r aot-neon ntpp�,r rs•e&O,VLY whit t4,,mot constr4rc6ona _.w cew
.sziamitmnr•jatrr+. S,UB 1ITT.AL INSTICHONS
9.Total well depth below land surface: 90 (ft,) 24a. For All %Yells: Submit this fans vviihin Sit days of compfeiiou of ivril
Fnr,ptiifrt air U,%r rrtl,t,lairs if,jdffirresu Pexamptw.3@QOri,awl:I¢'e tfprl commictian to the roltoniu^.
10.Stacie water level below top of casint (tt,) Dh-Wou of Water ResommeY,Information Prucessing(snit,
tOnwe r kvd is J;boty is flf*%Oste"-} 161.�Ti Alan Service Center.Ralckth,NC 27699-1617
ti.Hordrnlc diameter..10"/6" (in,) 24b.For-Inicel ti t a ONLY: In addition to sendinz?tla�fomi to the ad"—s in
24a above, also sobntit a copy of this futtll vriliin 30 days of completion of ivell
t2.Well cotrstractiolr method:Auger/Fluid Rotary colistniction to the fello%vingg
(W.m -r.nAma .cable.direct push_ria.l
Division of Rater Resanrcc%.Underground Itejeetfou Control Program,
FOR WATER SLPPLY%VRLLS ONLY: 1636 Mall Service Center.Raleigh,NC 27699-1635
13T,Vidd(rpm)NA 17etltpd of test;NA 24c,For Water Su iv&%jection Wells:
Also submit one cop}• of this form vrithirr 30 daysofcotupletionof
13b.MAnfectiantypi_:14A . : . Amount: � _ well construction to the counly Itcalth depatiment of the counh'wirer,
Ca?It.4Irt10ECt1.
Fans GW I NNonh Cataiiata f gaaneua of Emimurcat aid":antral TtasaUrves--Divulor ofjViiicrRemuzz Re ised ila4tsl2013