GW1-2022-10499_Well Construction - GW1_20221118

S
WELL CONSTRucrm RECORD F411.liv 1UsoONLY:.
This form can ba used for single or tnultip)c rsclls
1.Woll.Contrtctor Informatiou:
`MAYATER ZONES
John Eisertman FROM I 'to I Dr•SCRIPTION
W01 Cortrrhor NamC ft. I ft.
4439 ft. I ft: ' i
NC Well CoWmctorlcniftcation Nuwbcr OUTER CAS M, tfor rnulll-coved we lifOR LINER(ft-11 'tkabkl
FROM TO 1110TETER i Tif1CKNESS MATERUL
SAEDACCO Inc 0 f4. 30 ft. 2" la SCH-40 PVC
Calugrutl Name. EG_IN\_lE_RCiSING'ORT@B(NG:I iiact�e'rro+tctuuJtoii'i
FROM TO DIAMETER TtRCACESS MATERIAL
2.WcIC Constt•uc(iriil Peluiit#: ft, (t, n�
Gsflrdtrp}�7irnbh:v.clfprneih.(r_r,.C7UntV,Sta:r,lirriarrrr.Ir�leCOf�tot:) R, h 41.
3.TVcll tjsc(chccl:{vcll uric}: -17.SCRL N
WaterSuppW Well. FROM I To WANIF..TeR SLOTSlrr, THICKAFSS I MATFRfAt.
OAgdculttual. C11G1tiniciptUl?ublic 30 (t• 45 (t• 2^ i� 010 SCH-40 PVC
DGeothemtal(Headng/Cooilog'Ripply) ©ResidentiaiWater Supply(single) f4 fL is
Oludustrial/Coniniercial ©ResidentialWatcr.Supply(sluted) '1&GROUT _..
PROM To. MATERIAL EMPLACEMEVTME11fODA.L{IOUNT
171rri lion 0 ft. 25 fL Aqua Guard pump
Non-Witter Supply Well:
Edhtpni(cirinG GRccq{'ct}' .
Injcciloa Weil: n. f4
17AquifcrRccharge QGiourkim-acrRcnlcdiation 49aAND1GMILVE rwcKurallli�,nt�l=
.'FROM 70 NIATF.W.I. R\IPL%Ct-tIEYT NIMROD
C7Aijtlifcr-Storage and RCcoy�cty ❑Salinity Rimer 28 r4: 45 p, sand #2
17 AgnifcrTcst ❑5toilmt ttcr br linage
ft.. tt.
C]Experhucntal Tcclniolotw OSubsidcrlcc Citnlml.
2a:DR1LC1NG'I:(1Gfnllaclt:additional nlarlR if neccssariY
nCrothemmt(Claied Loop) OTr.tcer FROM To DFscRtPno�rmur.naCtlnep irRaackh a Win.Baca
I3Geotlteunal(Heatine;CuolineRetutM ElOilter(explainuikder,i*21-Retualles) 0 it... 45 t4 Silt/sand/clay
fr.: fL
4.Date WoU(s)Cm)iplcled: 10-14-22 pycil Ipprlw-z ft. ft.
"t• Y "d�k
sa.Well L IcathmS f4 ft.
Farrar's Store ft. 01
Ncilhp,'Ox•ocrNam FacililyID9(ifapplimble). R. ft.
397 Farrar Store Rd., Stokesdale, NC, 27357. ft. ft. �1j;!t1fu;1
Pllti shill AddrzssL City and Zip �21.R1:hlARf►S"
Guilford Bentonite seal from 25-28ft
Couulp Parcel Willific,llion Na,(1 IN)
li,l.atitudc'anif I,on'`fadeju d s/mitiutcslxcnnds or decimal t[
� egri� qr ' 22.Cet'titicafiuR:
(iftrcll 1,341d,4m IaL7pw;ig srdlickr4}
N TY '� y" - — -- 11/5/2022
6.Is(are)the{YellgS}t MPermanent or OTelnparat}' {Grr� i�fr�liZ^�' Y %i(u ;f8 31j '� 1<rr�fnrc7rd drt dcrorrlancr
t6irh'Im NC,tC 03C .,k*00 It elf Coitstivriinu Srcuulards acid+luri a
7.l,;this a repair fa an 6 tin;;n'elli iDVtm .or RINn i'<itmnj'rhdr rcrani libS'f s en prim4lcd ra the sir!!nivrirr
if rhls:11 a repv.44 fill Car 0.oirvi tti•tll cvtrtit ivitia hrfom47t:cn marl raplvin dit!owrure of the
i cpairurclrr E21 iernark5 srclie n ai rxn r8e lireC of rhia farm. 23.Site dla}tram or additional%veil details-
You alas,use de.bae6 of this page(o piovide additional%cell site,details:ar%cell
S.N utherof hells couslntcted: 1 constmcdou details. You iiiay also attacli idditionat Irises if necess:lry.
For judd&tttlerilwr tilt,rxHt,rrerersupldyw�-MONLYivirhtlm.artmeeerastrurriwr.ycueeur
sebmirone form. SLMNIITTAL ItVSTECTIONS
9.Total.%%' It depth betow land surface' 45 (ft.) 24a. Par All Wcllsi Subudi this fann%vitlri i 30 days of completion of µ'ell
For nrulaipkivells'lrsrrrdlrleprhsiidlfiwrit(Carartpte-3@21)'aul.; construction to therpitoningn:
10.Static water level below top of casings (ft.) Ilivision of Water Resaarcis,Information Praeessing Unit,.
lfnruCv kvr!!s r1hol.t edIIN*iw"+" 1617 Mail Senice Center,Raleigh,NC 27699-1611
11.Mrcholc diameter.8.25" (its) 246.Fnr Infecticrll Wells ONLY: In addition to sending the fomi to the address in
24a above, also sublitit a copy of this foita idibin 30 days*of.Completion of twit
12.Well construction method:HSA cousimcdalt to[lie following:
(i.e.Auger,ioda ,c bk-1 direct pusk eta:)
Rivision of Water Resources,Undcrgr ound InjcCdau Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 hint[Semice Cooler,Raleigh,NC 27699-1636
/3a,Yield(gpim) 4lctltod of test: 24e.For Watei Sup(tlt•.Kc Injectlort Wells:
Also submit on-- copy of this'fann within 30.d#sofcotu01etiolt.of
13b.hisinftttiun hpe:, Amount _ %veil.constmction to'ihe county llcallh dcpattmcnt of the connty where
coostnlctcd.
Fonu GRCd Nonlr Comliiia D.Ixmnwiu.of Euvimiuunu•aud natural Resources-Dlvi;ton of It'aler Reatref, Revised August 201.1