GW1--05700_Well Construction - GW1_20230905

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WELL.CONSTRUCTION•RECORD' Far!Nana!tlsc ONLY:
' ThiS fonncan bcvsvd for ghee or maltiple wells• .
1.Wclt"CanirnetorInformation:.
`IL-.WATERZONES "
Stefan Smith. FRpM. °W DESCRIPTION '
WA Cotitreetortrtnte ft. ft.
3576-A (t. ft 1
NC.Well CalnrectorCcrtift©tiontimber t5'OfffER CASING(rov iitutii`eistif iiitisl OR LINER'flf ati"tkahk) <•-. _-
FROM ' TO' DIAMETER. '. THICKNESS -� MATERIAL
SAEDACCO ft., it.- - .
Com i;utybiaatc• -t6:=INNER CASiNG'OR TUBING igiroE6eeaf it"eGused-laipi"
FROM TO DIAMETER. TIHCK{NESS- MATERIAL
2.Wett"Construction Permit 4: 0 . ft. 5 ft, 1 ', .ilk, SCH-40 PVC
. List XI oppi cahlo tscil prmif fix.Caunty.:Staie..11a►imrcr,f ecdt cur_/•
3Welt:[fso(chrxl:Stei. l rise)":, r175SCREEN - .
WatcrSupply Weill' .�bs1"� TO - DIAMETER M.OTSr7.E TlnCteNISS MATERIAI.
Citlgticultutal - OMutucipalPnblic 5 R 15 ft. 1 i� O10 SCH-40 PVC
IaGeotltennat(HeatinglCoolina Supply); ,®Residential Water Supply(single) (i: ft.• M.
®industrial/Conmtcrcial. ©Residential Water Supply(shared) "t0:GROAT
FROM • TO- MATENLAL L\tP[.AcE.ME•rmEiironRAMOUNT
CI irrigation• . . . . : (t.' ft. • I:
-Non�Water Supply Well:. . . . . .. .,
@nMonttnntm l=IRceotrr? ft, ft."
• Injection Well: - ft ft. " '
0Aquifer Rccliargc l7Groatidnater Rciucdiatiou . 7 t9:SANDIGRAYEL I+ACK•ir.rytplictetel:° - ,- __---_ _,
'WHOM, 7ta. . . MATERIAL EMPLACEMENT;w-vuna -
. h]AgnifcrSt9ragc and Rceoi`cty 17Salinity BiliOcr ft.: ft,•
ciAgirilcrTcst" C1S1onnisatcrDri eiage f6• ft:
l7Eicpetimcnlal Tccloolo •" i3Subsidcncc Control '
•1e DRILLIII C LOG'(altach adillllooal iheets if aeccssar')-
tGeothenuat.(ClusedL•oop) "DTracer .FROM• TO DP.sCRIPI1ON r.haoineti.vaWmck Opt:t�nOm.de.)
utlteitnal(HeatinyCoollue Retwu) OOtlter(explain Retuat6sy • f 4 ft.�Cr -
4.Dati Wags).CoutpleIed; e/16/23 Veit .it:' ft, l \L-Li t y i(J`t )
5a.Well Location: .ft. ft, S E P 4 5 2023
Forest Oaks Circle K . . ft.- ft,.
Faciiity,OtvtxrNamc Facility 1D14 0fapplicublek R. ft,. „ " iftitIt afi:rl f:,•G54_arR,_t�
5324 Liberty,Rd., Greensboro, NC, 2740 6 ' "It. • "ft, �r'�l.bt
P l0sicca1 Adc4ssi City:and Zip 21.REMARKS' .
Guilford. • •Temporary well for grab sample "
County Fated Identification No;(PIN)
SG;.Latitude and:Langitnglc in degr>seshninutes/seconds ae dccimnl degrees: 22.Certification:• .
(if nell 844 one I..iLlotto I+-Stiff ckni)
N W �`1 - 8/24/2023
Signal"•. ofCe.fiedWcfCnticictof Dale
6.is Wu)the t]Perolanent or xlTemporar}
IP!rlgnimg.thiY Pion,1 hrrrhy certify ihrtr the n•r11is1 vxtr(t,rre)ctmrttirctril trr;m+t'orrlmtcr
with I5,t NCAC 02C.0/(►?or.l5A NC1C(I2C;0200 UR U Cotcsln r,iolr Srarxfttrda ynd rhar a
7.Is this..a.repair 411 existing veili 17Yi.t Or FOND p'of nut ieronIiirib'urea prari erI ro the su ii mr ,iur,
If thisIt a ri'pc.Tlf,f all ecir towlt7t'le al!ivintmtct/oti htfo.rtttoi)on,7ir1 uiplahr rht:nature of the
repair Wilk".021:t nrirks'.seGiun or on the hulk ofM b'form. 23:S4e diagram or,utttlitiounl weir details:
You may,use the:Web:of this page to provideadt !soda!well site details'or-nell
8.Numbered hells constnicted: 1 - - . cousiniction delaits..You May lLii•ailachadditional pages if liecessaty_
For timid&lrtfeerlxnor maul-mar er suplydy u sits ONLY irlth thins eouttrtrclioa,port seal
547)1Ill 00C font. ' SUBMITTALINSTUCTiONS I'
9:T0tal well depth betow-land stirfaci 15 . . (fw) -24a..Far Alt Waist' Sirbntit this form within 30 days of completion of welt
For tnnitiplc ii7r1Is lisr all deprin Indifferent(maniple-4100 asd"2O 101)) •- cousin to the following:: '
10.Staticwater level llelue,top of casing (f,) Divisitun of-Water Resources,Information Processing Onit.,"
*wive,tare!it above casing,ure"i" t617hIail.Seryice tenter,Raleigh,NC 27699-1017
IL Dorehotediameter:2,25" -(in.) 24h;Fur lnjt tlup Wells ONLY: In addition to•sending:$he fomrto the address in
24a aliove,also subtuit a.copy of this lotto within 30 das�s*of.completion of hell
12.Weli construction method: DPT consirtietlon to-he following:
(ic.auktr"ia(ary,cable,'direct push:etc.} - 1
Division of Water Resources,Underground injection Contra!Plograttl,
FOR WATER SUPPLY WELLS ONLY: 1836 Mali Service�cntcr,Raleigh,NC•27699•I636
13: X(cJdIle,For Water Supply&injection,Wells:.
4 (>;jio) Methodnftest: Also submit"one copy of this Orin Within 30'lays of completion.of
well constmctian to the colony health department of tine county where
•lib:Disinfection type Alnapat: constricted. I
Form GIV-t l4on1t Carolina Department of Eat•irottn,cnt and Natural Resources-Division of Water RLtauttm Revised August 2013