GW1-2022-06948_Well Construction - GW1_20220601

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`? WELL CONS` RUCTION RECONU ror lacnml Uw ON .
This Perin can N.owd.for.singic or rnultip)a+►'clls'.
1:Well Contractor liif(irination:
`14 WATER'LON!_4
Stefan Smith FROM. 'TO DF.SCRIPiION
Iti'cllCaiatr"islprNaitic fl. ff.
A. n.
3576A
NGWcll'ContractorCenifii6i ion Nin&er 15."OUTER CASING-(ror inulfk-&'Yl'ncllsl OR l>INBR Ikabkl
FRom TO nM..T: TInC q7 \IATF.RIAL.
SAEDACCO Inc 0 It: 9 it. 2" in. SCH-40 PVC
('oligrut)•Name i6ANNER:CASING OR-TUBING'i keo� theimat ikiwil-lu,l) _
FROM I TO I DL\VETER. . THICKNESS MATERIAL
2.well.Construetion.pOiTilit N:
11,,.rrrrr�,ilii:r,h„rrrp.•„r�;tt U ec-.) -�- ---
n. n. in.
3,Well Ui c(check iMl u3c): P.-SCREEN
Water Suppl}'Vi'cll: FROMTo n1AatF:TSR "SLOTSV3: Tn1CKNIN I MATERiAL
tDAgiiCultural- Uhtunicipalff�tbli,c. 9 ft. 24 h. 2^ :.in' 010 SCx-40 PVC
ft.. in.
DGeollicartal(11ca[ing,'Cooling Siipph•)• pResidential Water Supply(single): !
0111dwrial/Conunercial IDRcsidcn(ial.Water Supply(shared) la:.Gltotrr - .
FROM 'TO 31ATF.RUL I ENIPL\CE,%IENT)1CTIIOD t ANIOIINT
OSnieatiou 0 it..: 5 it. Portland/beiXonite
1\on-Water Supply Wcll:
ohloniloringg Dltcco►vy .
injection.Well:
QAqutfcr ltcch:irgc GlCroiflidi+-1IcT Rcmcdiadion- "M'SANDJGILt.VELTACK kfati 1 14:1 tlLl
FRfI\r " I 'TOI AL4rF.KIM, MI:n101)
❑Arinifer Stora9c and tn;ot'ct), ❑Saliliify Bamcr 7 A. 24 ft. Sand 2
nAquifcrTcst MtomricatcrDr,►mi-c: fL ff..
OkNllcrinrcntll i'Rhnolo�n ❑StthsidcrFcc(;ofyml
20:T1RiliLINC'1iOG:(dtlrcb additional tilirets'if,feaicnnJ'.
❑('r.Ullicint3l(Closed Loop) DTracer I FROM I.To I DES('RIP.T10%kobi,hardiioi,wll'swkNu.g•ikinvm.(10
❑&OIliellltal(13ealineJCooling Retwn) ❑Outer(erpiain tni&r#21 Remarks) I 0 ti,.124 ft. Clayey silt
ft: ft,
1.DaleVell(s)ConiplVIedf 5-12-2022 III D#MW-16 ri: fL
5a.NVi,�ll 1.(ication:
H.B. Fuller Company 71. ft.
Fact7it):'Oxn r�1mce. Ficiliii:lD1!(if apple able), - _--~' '°A'"
3005 Holts Chapel Rd., Greensboro, NC, 27401 ft, fr.
Plt)si;alAddrsaCiia•andZip 21:REPIARKS'± "
Guilford
2 foot bentonite seal
\•
(fcnuth'," }�'Iri:C1 IdtltlirtGliiUD,Np.,(El.\)
Ste:Littitudc.ariil lApgjtirde in dcgiicdminutci(sccnnd4 nr"ilecirnit il\ Itic t. 22:Ccrtifration:'
(if vi C Il ft�id;O,b I:ttllitug iS Sall is i�id1
36.077554 79.751268 M1_
5/13/2022
fCcYflcii\�'c11Con►r.)o[or DaicR �SF
6.is(atv)the+\'Cll(s)i-MIRennanent .or .07feinporan' Hv s'igniiig,lJris(i.n":,l iterrbr vr,k,-dloi al,e ii-ellis)Ims 6wir)ivirrrr"i•le'l ire ir'cordcnre
irirh'15A MCACO2C,01M 1.15d NCiiG'02C A209 Well Owisri-uuk-oi Stiiivlards Unr1 Avil ci
7.L%,thlV a reliair'tn ati c\i%ti[I(;\1Cll:-; 0Vc.S '.(1r xNII cry'r)t6jrlliz recoirl1w,Nra,prkn4ilid iglJ;rzrvlJm,'ircr,
//rlvls re n rr jx,Jr,fill{�rtinrnrn ierll eerisfnri^11arAifurn><zrion'nnr!r_i7,lobt rhe_>utr,,rr trLrltr `
i.�;rrirwirlrrS?1 rrnmrkr]rriiarr brrvr Jir brrrAgfthis fon". 23:Site diagram or:rdditionnl well details: _,
You lvia)'use I PK back of.thus pige to proVid�.idtinlofial ti+'eu site dcial s or well
8.Numbcrof+\•ctls\�instriieted: 1 cousuuction°iletaiLi: 1'ou:ufay:IISO i11f:1CI1�dlllliOnaLplb�eS if 1lLY:eSSSr�'.
For in111drie i'dcknn i•r nia'i=iviirer t,rppti n 0fj 0iVLY rridri/m.sn,ur
s corisrruirioii,;}n;cniu
«hniifmle form. &I il111 1L.TNSTCIC7'10 C
9.Tkal:n'cll.dclith licloty nil A 4aee: 24 ((t,) .24a. Por All �1`cllx:.,Subrvni this form'within 3U.dcii's of colnpletioti ol'.++cll
Fnriu,ihipJr"iclBl1trqaOdepillyIfili'lireiiitra'mapk'.7G_+20)`mal'26I{k))' consinicliontoilidfoli'Ming:
1(1;Statit+vatcr Iercl.Gclu++ tup of cashll;: (fO Dli'isiun of Water Rcsources'lit(, atidli Pruccr in,'Unit,,
If umee level-H nhodreiiiiir:_nk,"�" 1617 MailScr'+'i& 'Lntcr;,R kleii;h,SIC 27699=1617
11:liorellnie diamcter:8.25" (in) 24b.For In liviio1'Welk ONLY. lit addition to sendin_n,(lie form to the address in
`24a ol'e. also submit a copy of this fonu.►+nhm.36 Aas•s'of Couipletion of
ab i%till
12 NVell c n stniction method: HSA const[uclioil to the following:'
(i.e.anger.iotdr),cable;dixr f rush etc_)
'Division ofJVatcr.Rc ourccs;Unitcrgroutidlnjcctirin Couh i Plci-�ratn,
FOR WATER.SUP.PLV WELLS'ONLY.': i636 Mail Scr+'ice'Cantcr,'12irlrigli;tiC27619-1636
13a:Vichl(gpni)-
�'ictlirtd(1f test 24c.For water Supllh�.&injection NVcll\:
rUsb�slrbniil on ."copy of I its forni.►i'itl>in`1ti.dri+sofconiple(1,not
13h Di ainfcctiun.tjlii _ , 'Amount:,,-,-,.�w - well constroction 10.1 cinmq k.nith dcplltmcut of 41c conn1v.wllcrc
constniacd.
17ann G11`-I' N'onb Cmolint Wpann em of E[rciroiu[knt ai d N,yuual Rcanaccs-[ii►'afon of WalcrRrFotrc� Revised august•N31.",