GW1--05811_Well Construction - GW1_20230912

WELL
� ,
WELL.CONSTRUCIT[ONRECORD rorltunraitl5a.otaLY:. r
. `!lrb fonncanbc•used far.singieor. nrtdiipk was.
1.%Vdll.Contr.tetur information:
• •'tJ WATENZONIS' . -
Stefan Smith. FROM. 10 'DESCRIPTION .
W01.1CoirltauorName - 1'8.3 R. 25 ft. I
3576A . . R. ff.
NC WI Commetar Certification Numhcr ItS::OtITER Ce1SiNG(fui~nidttl a iiininsclls}'OR I;1NER'41114 iticabtel'
GROM •70 ' . DIANItTER THIcKNESi " AIAtEMAt. •
SAEDACCO 0 .ft. 10, ft.' 2 i, .'is. SCH-40 PVC
f omputj-Natr . 'tC:INNER CASING'OR-TUDING;{%OtbcfnfaI clued-lei p) _•_. .
-FROM _ To DIAMETER THICKNRSS MATERIAL
2.WclR Constr'pctuin Perutitli: 2023-20-05-MW-5-RW0 ft, ft. ,iii.
Lifftrllaliplirnb7e,scu peneitri_e.County.:Srar!r:,Variarree.1rtfeta ir}err...): - �'
ft.- ft -
3..WDUI.Ise{chackavell tasc): ;t7SCIEt N
-
GROM 7o UtAMETF'.R . SLOT 517.E 7ttt(1c VA I SINIRRftit,
%V.i*r Supply Well:
®Agtirtilurial [I>viiitiicipalit?ublic; 10 ft- 25 'R- 2 ii" .010 SCH-40 1 PVC
•I1Geothenml ealin Coolie 'Supply) ®Resideiitiat Water•Su R. ft.- In,
(G S StPP�!#� i PPh'tsirigte) •
DludustrialtCottmtefcial •• . DRratdential WaterSupph•(shared) -`EB GROfFC, '..:_ :..:..
PROM 70- MATERIAL r Ebtt't.ACCOENT\fE1ROD.4AAICR VT -
Llttripatian . . . . . . 0 ft. 6 ft Portland • Pour
Ntm.VaterSupplyWelt:
idMgnitoring EiRecovely fL
Ittjectipn%V�lt: rt. . .ft,- .
ilAignifcrRctliargc C1(3tomiidwilcrReiitcdialtou f1.9:sANDIGItAVEL•RACK"pfuigiuiahtel ' ' -- -- - - =
'F•ROM. 10- • MATE:RIAI, - ,EMPLACEMENT
• t7Aguifer.Stq[agc aM Rccti%-cry� -ASalinity Haire 8 •R.• 25 ft. Sand; 2 '
El Aquifer Test DStorimiatccDrtlitage '
pEzlf;liRlsoQgl 1q hn4t4a. ASIthSidCDCc ijoinnal ;20.1/RfL'LI?G LOGrfaliacfirsaddilionnl sheets if neee.nIrrt
ofte lhetuaal.(Clu5edLuupj .DTr.icer. ". FROM 7O DESCRIP11t3Nhnbnharenu,sii14'nnlstrt+e,.satn: ..de
• OCrotlten►tal(lieauneiCooltuuRetum) OOtlter(explaiuunder:#21•Retnatks) 0 .ft. 12 ft._ Clayey .silt
12 tt: 25"ft. Silt it;
a.Date Wetl(s)conipleted:'8-4-23. Well iD#MW-4R . ft fL •i .
3a Well Location: 4 �-+�11'b p . .
f4 f4 it E G i:1
Jimmy's Daytona - . . . ; rt. , tt, c
' Facility.OwncrName Facility ON tfai pli..thle) • R _.. ft.:° -- `F-P 1:2=2Q23. -
2001 W. Vandalia Rd., Greensboro, NC, 27407 ft• •ft'. 1(1 ,fA3:irw'1?tC vi a
rlti-s l Ailihcsc Cit}'.and Zip <21:REMARKS . -1
•
Guilford -7852175495 • . Two foot bentonite-seal from 6-8'
Cotm1y. Pnrr:cl ttl•:iOrc,:adouNai.(PLN} r {
. ti:•L.ititudc'and.i inet'tude in deg' /minutcstsecrinds os decimal&grea- ',,,,;t^e. rid-fiend,'ra:
Owen t'taut.one li lll0u}i}f'8rdriciead}
36.020501 pi 79.839777 W - r Y . 8/10/2023
Sign3i 4 of Ce led Wcll Coiinactor j; . Dale
6:Is(:trel the treU(s}:x1Pecrnaneat ,or ❑Temporary �. i
Hy, stgaunE a 1Y him;.1 herby ear*00,14 rellirsl usury(write)eaarrrirrred krtecordathre
. tvrih jS4 NC+tC O2C.0100 6r.I sit NC4C-OTC4710011147 Currstriertar Startdcmfs and Ma ci
7.is this a relic-to an e.istingwelli DV& or No tolmofauc r rortf bri6boon i;rnaideol rn)1in n IP tnerier,
-(this1I.or ith fdlionkW:M141li+orcTar+:`rfoe(rrfprowridrrrmtleaivhtnrhoolornreoftic - I1
rep*((ler'kV.renc diseritun ar MI!iv bad leads/arm.. 23.Site diagram or..additional will details: •
You ma}'use the back of this page to provide';u1dl1ionat tsell site details.;or isell
S,l'ntubi.rof Wells constt-ueted: 1 consaructimt details, You May tlsd attach additional pages if neeccssaty.
For mahlple.Jrrfeerfoor Disler-neuter supply wells tic ONLY frith rlm.untie corrstrrdtiorp you ro ' .
srr6inir o ie farm. SUBMITTAL INSTl7CTIONS.1 .
9.-Totativell depth fo-elow land salrface: 25 - - (ft.) .24ai. For All Wclbu Sirhntit this form witlmi 30.days'of cdmptetion'of'W+etl
For irralrlpkimethslist all depths'ifc}1,tPerentiemonple-3@?(A0.rnd.2@100) constmcdontoihGfoltoRFin : ' I, . -
la:Static water•..le�e1 below top of easing: 18.3 • (t ) Dh•isian of Water Res'"tinircit t,Inftirniatiun I°toeessing Unit,
}/ache,loOolls k1iore casing;lac"+" 017 Rfatl.St iee t'Ccr<ler,Raleigh.NC'27699-I6 17,
• ILBgrclude diameter.8;25"- , •.in,) 2'�Bh:Fn- Nil tort W cll4 ONLY: in-addition to-sending the fomt to the address in
24a abotte.also submit a copy of thiis form within 30 days of completion of wilt
12.Well eotistttictlou method:HSA _ • . . culistiuctinn to Else folloti'irlgi• .
(Lc.cogs_audary,0,1.e„-direct gust.ctc.} -
.Dlrisioit of Water-Resources,Underground Injection Control Program,
FQR WATER SUPPLY t«LLSONLY:. - 1636 Mat[Service Pilfer,Raleigh.NC 27699-1636
24e.-For Water SRIipIv.&fujtxttiii Welts:
1341,Vicldt m) 'Method of test:
• Also submit one copy of'tins'fo'nri Within ail;days ofcottigletionof
" well-constniction to the county health depattnrent of•the county where
13b.Birint'eetir'un p e: Amount: 1
constnutcd.
•
Fonu GW-I onh Coroll us.Depan:nent of Eneitottnicta will NanDa1 Resources-D.ivisloo of Wale Rnalrtes Re%.ised August2013 •
I •
•