GW1-2022-10501_Well Construction - GW1_20221118

i
WELL CONSTRUCTION RECORD FgFNcnWUsc.ONLY:
Thf.s farm can bc'uwd for singlc oar multiple wells
1.WLM.Catttraetor Information:
'14-AMATER 1.ON FS
John Eisenman FROM "rtr DFSZ'RtPtlils
W01Colaracl6rranw
f4 fl:
4439
NC.Rrcll Contractor Certification Nmrber IS;OUTER CASING(iril i1ial11 rased iiYllsYOR LINER OUa`i lIcabkl'
moat TO niAmETER I THICKNESS MATERIAL
SAEDACCO Inc 0 (L.1 29 fL 21, in. I SCH-40 PVC
Cmtfgl:ulrNanlr. c6:INNER.CASING'ORTDBING:(•enihannrl cSukd4o(IiY
FROM I TO DIAMETCR THICKNESS MATERIAL
2.Well Construction PelTuit#i
lJsi(III amilirable Well pehlvitn(hr.Cntrrrty.:Va:r,.lrarinrce,fr ye:Mnl eir.) ®--
(l..
J.well Use(0epic iYcll ase); [7:sew eN
`E'ater5upply Well: FROM I To 13MM M -SIAT517f TnrckNPSs I uATnnrar.
I�Agttrultmra! CI1vliinicipaU[fltblic 29 W 44 ft. 21, in .010 SCH-40 PVC
M othennat(fieating/Cooling Supply) 9Residential Reiter Supply(single) ft. R: in
©ludusttiaUContnicrcial ©Residential WateCSupply(sbaced) '"18:GROUT
FROM TO stATFRIAL eareLACE,YrENr.vtt rtIOD h AYtoQNT
❑irri' tion 0 iL 24 fL Aqua Guard PUMP
Non-Water Supply Well: R, A
6 mkinhoring pRccovcry
InjecNott Well: rL It.
MAlliiferRccharge 0 roundmaictRciltedialiou MSANDIGHAVEI I'ACCiYir:rirdicinlel:° - = _
'9RO57 TQ' arATF,RIAI. NS1PI,ACEMENT SrtT11011
❑Aquifcr_Storage aril Recoycry OSalinfn'Hairier 27 ft.' 44 ft. Sand #2
❑Aquifci Tcst LlStoelmi;rtcr drnir)agc
1't. fL
❑E:tperinicntal Technology 13subsidericc(:omit :.p;mRIGE1\'G'LOG(apach addltiooal sdci9s if neccssari I
oGeothemcll(ClosedL•uop) ❑Tracer FRO it TO DF.5r,Rminoshnbr.hardnv",v,4'„xktr n-n.ctul
❑Cr:othewual(HeatinyCooliu2 Return) ❑Othen(e tpiaitt under 01 Remarks) 0 :fL 44 (L Silt/sand/clay
f4, fL
4.Date Wells)Campleted: 10-14-22 Nall II)#MW-4 _
'
Sa.Will Ealca tinn: f4 ft.
RI
Farrar's Store ft. fL
Facility'Ox•IxrNiuuc. Facilit}IUl!{iEapplichble},
accina 397 Farrar Store Rd., Stokesdale, NC, 27357 ft. fLv ��11
►) .rt�/ �
Pilysicul Additss City-and Zip 1L REMARKS'
Guilford Bentonite seal from 24-27ft
Counly Pa cl td_utitrcaUouNp,(PIN)
56.I ittitudc anil 1 ongiiudc in dC9Mcx/m11_lutes/sec6nds e'r decirtlal d.egncs: 22.Ce,tilYcationo-
(it%tell AM,One 1a190ug k safnck:,a)
R W _11/5/2022 m
Sigruwr of�r==.?r 7i. ,. :tF--- Dale
6.Is(itt)WC1YeI1(x): MPenflanent or ❑Temporary Hrs;grrb( Ja)s. :�Y �xri(r rr'' :f K Y::e'.l�^if e�2'LRL1'7NCItYPl11L'LY'OlYflfflLC
1('irh`!fa NGIC 0<^C.'r .'a iU�. �C,fi20A trill Consim i(en Cmrrrldnfs and rJvrr+r
7.Lt.thin a rro*(n as ci iatin;Well- ❑Yes Dr KN4b l'OJ7Y Of rJN4/CCOrYf)errs Jh'Pn pr4t'llfCd rn'iti+l cn 1(airrit r,
tjrlris.fi(!R pale,fill(nrr kRUll71 li'tll cvtrismrcrlan Grjormntl�n ttrirf el f�(ahr rlle�rlrrrrrrt+>f rfle
itpnirum'1er 821-rernarks.xecrlun ar rn the burl aJthis jnrnc 43.Site diagram oradditiouat will IICIaitS:
Yda may use ilia back_of[his page to"ptoc'ide addilional well site.details,,or vi;41
S.14mmbcrof ive1L9 eaustretcted: 1 consnuctimt detalfs. You inay a(S&afiacft iJditiou pages if tloc'ss Try.
For rimb1ple kdecrlon tft 00rr-DYrrer firppf)'U4'(f 5,�1`'Ll'mlrfi rfm.arrme curtslrairtiorr.you.o ar
srf,initnrirfdrm. SUBMITTAL INSTEICTIONS
9:Total well depth below land sut'facw 44 (ft.) 24a. Par All %Veilai Siibndi flas form within 30 days of completion of welt
For ntalrlplcivellf'lrst fell diTrhs(fdljferem(exappie-3d@20J'tTM2:f( ) consimetion to.Ilya fpllouing:
10.St-atic wetter level below top ateasing. (ft,) IIiVE'dan of Water Rc tmrcey,Informatipn Prucessing Unit.
?jnvree let-el is above cusing,rift^+'• 1617 Mail Service Center,Ralcigg,11,NC 2 7 699-16 17
11.Borehole diameter.8.25" (in.) 24p.Fnp Fje(Mtion Mill ONLY: In addition to sending,the form to Ilia adiifescs in
24a abd�e: also subluit a copy of this foitit within}0 days-of completion of will
12:.Well coustmetioa method:HSA Construction to the folloMim:
(i.e.auger.rotary,cable.direct pd sls etc.)
DivLSioit of Water Rimurccs,Underground ImjeMon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 NL d Service Center.Raleigli,NC 27699-1636
13a,Void(gjrmj ?ac.F6r Water SuPoly&IDLectuin.We119:
rWfrtlrod cif test: Also submit one copy of this fame vsitbill 30.daysofrompletion of
13b.Disinfection type: Amauat: tvcll constmction to the count)'health deparimcnt of the counh,where
constmctcd,
Form GLV-t Nonli Carolina Depanmcru of Eev'iroruucnt and NaLuml Resources-Dieislon of N111cr Rrxo=M Mised August 201.1