GW1--07649_Well Construction - GW1_20231204

WELL.CONSTRIUCTION.RECORD-
\ (°I Vet.ItTernd 1. c pNLY:.
This form canW•useil car.single er tatipla Iv*. . .
1..WrIA.CMItOtrtar fttenimation:. •
. . . . .
. . , .
• 'ITAVATERZONES: • -. • ..' . • .-• - .
' Stefan Smith • - • FIMN1 TO nrSeittiaTinN
Well Contra-tot N:tmd. . ft; ft.
. ft: ft. 1 I •357 6-A
:35.OUTER.CASINGTfai-unift Viiiied-IiiilsT 0 R LINER:Oral)'titablel'1. ,.......
NC Well ConfracierCertificatienNuallet
FTIOI . ,•TO '. , DEANIETER• ' THICKNESS'' MATERIAL
SAEOACCO . . - f.1-t• - Ift.• • 1*-lit; . . . _
•
Contimm3-Name. jfisidtimticlsAligsgu. i J Jit.....___T/HING: ieettiiiinal ehiitil-loiitorlf,' —..- . . - •
FROM' TO DIAMETER TMCKNESS. - _MATERIAL_ 1
',..i..V00 tOOSOTICRIIII Fermit//: , 0 'fit 11 ft. 2 ; ' •lit SCH-40 PVC .
/4414illamiiiraige 1941 piayii4.4e.County.•pirhi,,yarlanci..Necilcil r RP '
.P . . '
.
. .. . , • •
3..Well 15% (OIC;I:VN:C111 DSO'. 117:-SCREEN-- . • - . , . . .. . . .
. . . _
.. ,
. - -- — FnOm.. •TO - .0tAMETER. st.OT SIM TtnetorSs ; MATERIAL
Witter Stipply Welh'
ItMtinidipal/l)tblie 11 At' 16 'It• 2- f.ii-' .010 3CH-40 PVC
" Eli'igtrieulttual i
.i . r.:.
OCreathennat(Henting/Coolini.Supplyl CIResidential Water Supply(single) • . r I • 1
•- - .CROUVE...., '
0 InduArialiConunercial, C3Residential WaterStipPlk(shared) S m .To, [ MATERLAL EMPLACEMENT 51E1110D&&MOUNT
ID Irrigation, , . . . . . . . . 0. 'ft.: 7 ft. Portland Pour
. •
NonAVater Sootily WWelt: .- • • ••
, , . • • . '-• ft; : ''
Nivlanitorhig . , .Milo:gym •
Injection%Veit: . ft. . . rtft... . -:I. . .
• LIAMtifdrResbar'0 - . • . • 1:1GitoundwalargentedOion . A92SANDIGILWELPACKtillipitlimliter .--" - .:-..i."-,.-.- .-, -
. . . „ • ...intOm. TO - " MATERrAL ESIPLACEAIENT mmtton -. .
PAnitifer_Steragc 0)4 Recovety ciSalinhy Ranier.
.... .... ,. .. . 9 R.. 16 ft. Filter' Sand #2
. ElAtiniteiTsit• ElStontiWatciliminage .
... , ' .h.. .(t. ,, . •
DEtiperituoalaiTcehnorqt:. 13SubSidcocc.‘toninzi1
...- - , ;-26:DRILLINGLOGIfittacti'additiorial shkis,iftecsaiii"-
itIOeathennut Plesed Loop) ElTracer FROM. TO , . DESCRIPTION tobr.bardnco,..ttiR'mett lox:min fik,ctic.)
EIGeothennal(FleatinolCooling Return} 00ther(explain under.f,t21-Retnadis) IR* . it,
_ . . . .
•. . ft GO'See s Logs
. .
4:Datii Well(s):CemPleted: 11/7/23 'NVel.1111#141•1-10
"ft. - . ft. .".trr'cI' , .:1 ,...,/,'-.
50:Well Lticatilml
•Ir.t..: rr,.
Sherwin.Williams . . . . ft.. ft,. .
' D F.-C. /. 2023
- . _ _ __ _ __ _ _ _ _
PacilityAglyncrNtaue FaFtlity itiN Zirapp*Ible),
. . . .U.—MEM ., , infom:2-4::.71-1 Pr.7.-:":.:f.7,72.f-1.2 URN
113 Stage Coach Trail, Greensboro, NC,,27409 . W. . ft,. ' Lly 4 1/44;15',...k 4 •
.P14.1ri*Adqi.-055,Cit3-.01 Zip•' r,21:REM11/t/tKi-% . - ''''' .' ' ' " . . . . •, . . . . .
' Guilford -Bentonite seal from 779'
• .
COUL1y PANC1 ItItailirtemlon No,( IN)
. ,51i.jil-Utitudeand-Likiiittle in degreeitutinotesisiOnds or dotiMal tiegreci: . .22:Certificationv ,
(11".well tglil,one latileit i601001,0 . . . .. '
, .
1C NV -..t,0)-4q/ t.K1/11 ! 11/16/2023
_
• • Sit of Ce,.fled Well Cetargctar- Date
.6.Is(are)the well(); EPermattent or ptentporary
ity xigning this fainv,.i Araby ecrtifyi 6,:tr.th..g wai(s)iya.:(14xim„.1 eawrinied kr/cum/mice
tiitli 15.1 NCAC 02t.0100 or 15it Isretic.ilZC:0209 Mt Cominierion Standards(yld that a
7.4 tftht a reitaii-16 au e.iistieg.o.04 Ely,,,,- -.0, EsTo. TOP:v.of(Ilk iecord iiiis lima provided'rev.the soil ditujer,
. eilli.stff 4 r?Pair.Jill Or lannvn WO congilfelion informiliOn aid explain the narare of the
a-0(dr adder O21.:rernarki`seditm or im the beikalthiv form, . 23.Site 4 lugFAM or.additional well:details:
Yen.may use th'e.bacli of this page tp.piovidiaddidonal well Site details or Will
8,Nutuberof Wells 6tostructed: 1 • Constmetion details; Yu May alsimitach additional pages if neeessaty.
For iltaldple inked&Or tion-warer slipply•weiig ONLY is•Jrli die.sinus.construdiOn, on von
SUBAIMrALINSTeCTIONS:,
0."Tutil Well depth below land stirfacei . 16 - (fo, 24a. Par AU Wellk• Submit this form within 30 days-of ocfnupletiOtt of welt
For ntairipkiVr Ifslist all dep.*i(differviii(e.varpp --3@200'm41.20100) • ' constrtietionle the fattening: j
I. , . . •
10.Static water level bele*top of easing: (6.) •Ilivishin of-Water ReSegreeS,Inforattition P.itieessing Unit,
,
if waive keelis above easing,Sue."+" 1617.1SLtil.Serviee Center,Raleigh,NC 27099-1017
11.iiarehaitc diameter:8-25" . . (in.) 2411.For infection Welts ONLY: ,Imaddition to.sending,the form to ilte address in
24a-abe,also sitbittit g..eppy of this forth within 30'days'of completion of well
tl.Wefl'ormstruction method USA - cotisinictiou nithe.folloWitte!•
(Le.attt.r..,trim,ce1:10:,dimet iuslarte:J '
' ' " . . Divhiaii of Water-1104u reC.E,ItifttdCttrannd ftijcitio n COntridirrOgram.
FOR WATER S.ITPLY WELLS ONLYf 1636 Mail Sersice&nter,Raleigh,NC 2769971636
i 1 Wells:.
24e.For Water Swift&Injection W
14atifield(gtim) :Waited of test:
.Also-submit one ciii)3., of this faun Within 30,days of comPletion of
1311.DisinfeetiOn.type: Amount: . .welt conStruction.to the county 1661, tli department of the county where- .
. , .. Construct6d.
•
Form GIV-1 Minh Carolitm Depatnneta.or Emicomneta and Natural Re:euteM.,Division el'Water F1meirces Revised Aoguut20l3