GW1--06691_Well Construction - GW1_20231024

• WELL CONSTRUCTION RECORD' crhiten,al irsc ONLY:.
This Corm can be used far siiig!e of nwltipk wells•• 1
➢:Micd1.Canti:tetorIuforauation: ` ..Q .
-11.t:WA ERZONFS: '
• Robert Miller \v` NWty1t. TO DESCIUPTIt)N
Will CoiiftaporNamd. ft. ft.
2675-A IL ff.
NCAVc1I contractor CcttifietionNuarbcr IKOUTER-CASING'ffopinaiticaaet0vietbfOR LINER'tif:ap"tJcabk)< .
FROM - • TO - DIAMETER• THICKNESS" MATERIAL
SAEDACCO .tt: ft.' I. i btu:
camas).Nam • t8 1NNERCASINGOR-TUWNGi(tt pctie_iufale6osxil luii»! '= i
.FROM TO DrAMETER. ThIC1{NESS. :MATERIAL
2.•Wdt Constilrctiou Pertaiit#; 0 R. 34 ft, 2 :ill. SCR-40 PVC
listull a i11 able uel pem+its.(i c.Comity.Stu:c,.trorimxe,til'd$1107-)
ft,. ft, it.'
3."Y11.0E 1lsc(citecl:.r'rc)I use): ,rr.-SC1tr,.EN • •
• tiPstter Supply Well:" FRorl
TO DtA%,RTtiR' St.(ITS17$ . TtalCIcstrtiS. MATERIAL,
17AgRduItuCrl1 Cilakurtcipal/Public,'. 34 it.: 49 It 2 1.iq,' .010 SCH-40 PVC Pre-Pack
• ®Geothermal(HeatingleooliagStq)ply) .DResidentiat WaterSuppl}•(single)
•
©indusinaliConmteercial , ®Residential Water-Supply(sitated)' '=tS GROUT'' , _
• FRO\I' -TO. MATERIAL.M. EMP ACEME?IT hlErilOD&AhIOUNT
l91rrigation• . . . 0 ft. 25. ..ft.• Portland Tremie
• Noti-Waiter Supply Welt --
fiJMpnitorin,g 1:1Reeo��stg _ R.. (( .. .
• In Lcelon W01:, R. . ft,
OAqurfcrRccli rge ClOiOitnAstteritentediatiou• 49:SAND1GRAV5L•PACR'firuitiil .iTtrk„ - --•- - : - -= '
I.BRO\t. .10 MATRRTAI, RUPIAtiEAltNT Nt?HOU
ClAgliifcr,StoI.age and Rceo ci}. -( Snitnity Harriet' 31 •R._ 50 ft. Gravel pack • #2
Aiinifci D test Sfoinii�;r terl3rt n;7❑ Sc
I7apetinrcnlal T6 htiotolr,,t� l7Sitbsidcncc Conlml .
.411.DRILL.1_hG'LOGialt_aehaddilibnat3hie1si1-Reoiisai.if-
ElGeodtemud(Closed L-oop) DTraeer -FRoNt• TO • nrscRIPrto'.tca r,'nroncn.u+alntt tnx:sawn ttul
9GAtheirital(HealingiCooliug Return) DOther(explain under:#21.Retuatts) " .ft.. -f4
1L; -(L
O
/
i 1i1�4.Dati.Wel[ ).Cduipleiedc 10-2-23 'Li& m#CPT-01-50_ F-.ft. f..
Sa:`Nail�l Lt catitn: .i, fy . - . ,, . . .
. OmniSource. Corp. . . It •
.- . ,i
•fla iity+Pit,r$anae Faciliy WI.(i(apph able).. R. •_ _ _ IfkJl7i 84?•^a1: y,�..:n ,, 1}
1426 W Mountain 'St., Kernersville,, NC, 272.84 . . . . it,, . . . .R; , . • C`ve;11; 0 y
Plg3icu!Aiidia s City.and Zir ;21:REMARKS . .
• Forsyth 'Bentonite seal from 25;31'
County Parcel ldaatirtai,lonNa,.(PI )
•5h,i:,htitndc'anil.Li ngltuile it dcgtceOminutcsts_eet nils or tfceirif:tl•dcgrccs:• 22:Ccrriticsttiuti:' '•
(ifuell field,one 1ai/ltyug il_Sr)n4i
tetd}
N '�v' " 10/2/2023 •
Sigmuuraf.':t. 2 _ � — - . Date
6.Is(are)the seli(s}t EPenu.tt@ttt aC DTeniilorat J s gtarng.galfa•.Pm..1 hereby.ecet6 that rlahill(.)iat.i(rtrnnJ ryr 54drelrrI lrr;rre orrltmlcr
Ida[5A'NCrAC 02C;090 or 15A'NCAC 02C;U:OtO Ra•U Cnnsttrictiar Sromdarda gnd Om a . -
7.LL•that a isinurfa ad*Wag lycli' Oyer :or •EINu' - cep_r_ofthlr recomlliar lition pnnrlrlyd roltie sirll nun r,
if ibis:h n r pa!r,.fall cat firethv i a hell eearu?tarakrti larjorrrutr/on,rirI r.(liipbr nk noire of rite i
Opal,radat'cs?1»vnarke:s ilium or bn tc bw L of e4i.,farnc. • -23,Sttedlagr0D1'or additional.nell,details:
You way_use the hack'of thi.page to:.Movide,additional Well site details:or Well
•
8:1Cutuber'of wells constructed: 1 cousirtiction details. You May tl5o attach additionat.pages if necassaty. .
For rrnleipk!r{lecriiin arNOi-newer supply aeah(hL1'ichri rho same corrsrrtrrl5at,you c�CW ;`
skint tine form. . . SUBMITTAL iNST UC`[JONR: - -
• Q:'total isell iicpl4 li%lois land surface 53 - . (ft,)_ ,14a..Far ALL Wills Submit his Karin within 30 days of complclioti.of well
For iriuhiple itcllslistall depths irdlffemia to aaa�fv-3@2OtPanT12@117O1 .consUtrctio0 to the foltot%ing: ' ! - '
la;Static}tinter level below top ofcaLsingr (ft.) Uivisiun of Water Resultrces,➢nfirrniutiunFiucessing Unlit,•
tjnealer tore!is dare cgatog,ux"+" • ' 117 Mail.Stsh•icc Center,Raleigh,NC-276 -1617-
11 Sorc[aote diameter,6" - . (in,) .2411.For inleetlort Wells ONLY in•addition to•sending the Conn to the address-in
24a aboe.also submit a,.eony-of this faint within 36 dads'of.completion of welt
12 Wellcotas(rttetion method:Roto-sonic constiaiclioti totlie'following. 1
(i_e.auger:iotati.cable;direct pasts,cte.) 1 ..
• . . . . . . . . 11.11•hiaa of Water Resources,Underground Injection Control.Progrni,
FOR WATER SUPPLY WELLS ONL11' . 1636 Aiall Service j enter,Raleigh,NC 276r9-1636 ' •
• 13:r,'Yi�d(gjtan) :Method of test: •
?de For Water Stipple.At-Injection Wells:
• . Also submit one'copy of this.farm Within'30:day'sofcouipletion.of
'1Jh;Disiufcctiugtypi Amount: - welTcoiasiniction_to the county health department of the.county where
constructed. •
•
Fanu G*-1 MtrihCamltna Dcp tune u.otEtniromirnr ami Natural Rcrourcc9=Dlviilon ol'Watc fte'atttx Rclrsed.Augtast 2013.
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