GW1--06698_Well Construction - GW1_20231024

. . I
WELL;CONSTRUtTION RECORD. .
Fcrltiemalli*.pN_LY.:.
Th(i•fonn cot bellied fir Single or multi*ice114.
1 '
•
I.WUR-CholkittlOi•futoiluillIon: . . .. . •..
•
.: 14:-AVATHR,ZONES!. . •
' -
Robert Miller . . FROM. ' TO DESCRIPTION
Well Coritractort.44une, ' ft; ft.. .
if.4 f.f• I . . . •
2 675-A
'1ISOUTER CASING'adriiiiiillitiiiil ticilsf OR LINER:Waif-tiCablef,- .-:-.
NC Well Cavil-actor CenificitienNmilbef
F.ROSI • • TO -• DIAMETER.- . -1THCKINF.SS' • MATERIAL
SAEDACCO . ,' . , . .ft.i: . 10, • , In. .. • ..
•
ComptulyNOFIC. • • . - ' • ' • 'ICANNER.CASIINGTIETTUBINGIttinthinnilefoicil-lonjW- - r.
. • FROM 'TO DIAMETER THICKNESS.. - MATERIAL
2.WCilConSuntilditOcrttiit Wi 0 'R. 5. ft. 2 1 .'111, SCH-40 •PVC
-4.Itnif 451.11010.719,41i6F4t, (4C;C9InitY..P1119.Arad aMee,I:1 feCP4 4 0'7) ' in.
. . . . . .
$.*ii:i.j.s-r-(t101e:0/..01100 .
• • 17...-soREE.R
• WitterStipply-Wellv . •,InANtr.tlin' STOTSIZE 1111CNNESS , 51.41V41A1,- _
5 ' ft 15 .TL. 2 .0. ..010 SCH-40 PVC Pre-PAcfc
ElAgriodintal pl4iiinieipahPtiblie..:
. .
• 1;Idedtitennat(HeatiniCooliot Stipplyl:' I:Residential Water SupiilY(single) • it ' • It'. • •_ -19' . • ' • ' • •
Ellodustrial/Contntercial CIResidentiat Watet;SopilY(stuted)..
FROST ' -TO. NIATERIAL. • '--ENtPLACEMENT METTIOR&AMOUNT
Clinigotion •. . . , • . • - • . • 0 it.' 3 it;' Portland .
Tremie. . .
,. .
ND ti-W4itcr Supply Well:: . . . . . . .. ._ . .. ,1 . . . . , . .. .
• , . : .,. . .. .. it,,, . ,
• fi9);lonitoring • _ IZIRccovety
- - '
Injection Well: • . : ft ra. . ,.. • • - •
ClAintifer*050 • • CI.G0iindsrateir acrocdiatiott : .,t9ISAND/GRAVELPACK'tifilogiliegAter' - .'--T.
.
. .. .,...,,..,,.,
-4•110•Ar •TO • MAMMAL, ' - •EhIPLACIMENT.MMlion • : .
liAntilfcrSitnngc and l'..ced'i=.ey liSalinitYDiiiriCe ,
„ . .•- 4 "',It':, 16 ft. Gravel pack - #2
. , . clAiptIrcetco. a*ainiiiiiti'.000.10• .
., .., .- • .. . .. • • ' . •,fl7._ . •ll! ' 1. •
• Eliverinieutal 71:41todro . 31
a. 1.tStlbOicnce:CdOirol • - •
• 0.DRILLI EO NGG'fathiCh4iddliikinal stieetilf neeeisirrf ..
•
lti.4tolitO ( .nnul [444140p)0 tar:deer, • • . • . ' ,FROST• • .10 ": --- DESCRIPTION reatir.reroncttomoinsli nor ossio`AAN cit.)
. .
EIGeothennal(lleatingiCoolindRettunl - Obilter(tSpiain under..#21-Retnailis)
••ft., ' ' It .. . . .
. • .
4:Diitit WelifsjCoritpleteili1(1-4-23
.r.t-, ' ft•
. .-... . .. . _ F.'""1.,,'. .-,..,-....,-...—_.., . •. _
54.;%WI tAie.atitief . ' I.E. •fl, r'''',L.--1-•.,k:tkil-_.---.11 -
- • . . ...,
OmniSource.Corp. . • II:. . , fc. ' ' . • .
Fie.011y*ne i;Ntimo - - 604'ID#Ol'appli'-..Chlei, , —4-14.
• ''R. ' • 1•1•; •
1426 W Mountain St., Kernersville, NC,.27284 . ft. • * ' I nto-rir,a:.f cn Prc7.-a,;_461,13 Uti*
. ,
.ii16.i*F'AddtKciLi'- 4'• 211.1•AtAltriS- . ' . •-
Forsyth ' • •Bentonite chip seal 3-4' -
,
• •
. . •
• Cotally- - - . P4tcellf.k.noteiptiouNo;(111,N) • • . .
:
Sii,,Latitude and:1;004de in ilegrceihnlikuldi.s.ceOnd.Or-dccintuttlegifeci: •22,eirtifieall'om. .- .
(ifmin flottli ono lailloit is..itilllleol) .
p....o .
. .•
, . . .
__ N' ' • 10/5/2023
. . • . . .Sigualore di..s.;:e.iiiie:il)-,':;47'.:,?;:-.^.....f..:;.;'Ao, • Da.•1..F •
. ... .- .• - .•' •`'-•.,. . .: ••••': :L •,',;•; :, _. .
6.Is(ite)the:well(s); 10Perntanent 'or -oTeAtigeroy if).si.:9;ning.,this:him 1-Irerelg terrify 11 the
,42 r• .well(s.)il*s•itp)qirvirircte4 lo.,A,Orfisocv
• . .. , . -..iiief 15,4.AVAC 02C.010 or.15A Npic.•:PC:P209 Weld Contrikricuigrcion'ords gin,rim d
. 7:bi•this,a rep*-itit alq_iiStintiWilli-• EIV4ci ].or ON° • :i.ciiis7pf rtikii,00f biii&Ten froikifted rO#e•o:ITli(iit•rier.'
If Th(s'.Ira repair fill 4-0 finoun ii'd1Ootktnictioti•WertnatiOn era likpf41n thendrare of the • . .
te,pair oOdEt 021.-tOrnarkirsecitaii or im the bail of th(i:kiln:. ' :0:attedingrnin or additio nal well details:
You niak.use die.bock of this page cc 1prOidellidthfidital well site details or welt
8:INuttther of Wells Constnteted: 1 •- - • - constniction details:•You inay illsitattaett additional pages if necesSiry.
For tituldp/i iniectli-Ot'or rioti--mner supialy wyt(s 0/IL)nitlu'rhe.stretqemestruilik you e40
Fablillt Oc.icirra:.' • SUBMITTAL INSTUCTIONS • • ,
. . .. _. . . . I . .
. . •
' 1.-TOtal.tvell depth lielear lanirstirface.'. 16 - • - - (6.). 24o...Par All Wink.- Saila thi ,sifortit within'30 dnys•of.coinpletiOii"rior*Il
For Toldpk.ii:TlIslisr all trepdai fitilffiyou•(example-3€12.(i0'and.:2€100) - ' .constnietionlo die totrossiog-, ' 1 '• •
. I.• . .
10.StaticivaterleVel help*top of 644' 00' Division of Water ReSottit ii,lnfortnationProCessing(foil,
litontor 14,k gl•if shore cid,sfitg.•tise'"+" _ ' /617Aliail.Service•Cdinfrr,Roleigh,..NC27699-1617 .
., ': - • • • •-" '
11.-Dorciniic diameter 6" . Ain.) .24b.rtir Infection Wellq ONLY dn,addition to sending the form to the address m .
24kaboie,also submit a..etinY'of this forth within 30 da's of contplOtiott•Of Well
12:Well poustnection.method:Rote-sonic construction to the f011o‘ifini!• '! ' •
(i.e.uuketiotry.ozhIc...aireq push.eci.,1- • . •
. . . s 'A • hDvhiai Of Water,Reonrevs,Underground iiiian Control Pmgraui,
FOR WATER SUPPLY WELLS ONLY;* 1636 Atli Service Center,Raleigh.NC 27691,1436
. . .
24c,For Watbi'SENIT.cttujOttoultV'tlIN:.
. ' 13a1OriFid`klitu) Method of test:
• Also submit'one. COD) Of till*iffirin tVithin.'30.104s of completion of-
lop..Disinfc-ctionpre Amount: to to fhb county hedltli department.ot the coinity where
.ty
- conittocted.
Farm GW-1 'Wilt 64rolina Dcpalmeot.pf&rimmed and Natural Resources DA'S Ion ot Woter flt.otr. Revised Aqust NB
!
I