GW1--00053_Well Construction - GW1_20231218

WELL CONSTRUCTION-RECORD A/ Far Iricntal Usc ONLY:
This form can be used for siiigtc at multiple wells.
I.%Ycli.Couttactur inforutatlott: t • . i
John Eiseman NMI • TO nti,SCR[PT1ON
WellCeintradorNiiad. ft. ft. I I • ,
9439-A ft. 14
•
NC Well ConImc1arCcfflhlciUon Number 'ES OUTERCASING•ifur ntullkii d-nct MORLiNERilfap licablc)' _ _
FROM TO no.arr ruin THICKNESS MATERIAAL
SAEDACCO 0 ft. 68 , ft. 6 ! !in. SCH-40 . PVC
Comp:oil-Route- • • .t6ANNER CASiNG'OR'1'U91NG utherMal elacil4uiij►l'/,-_ .
FROM TO - DIAMETER THICKNESS MATERIAL
2,Wclf"Cansttuction ecru it 4: ft, ft. I 'hi.
List id applicable well pernefi.(cc.County.Srn':c,Variance,flia001,err,.) Ft, ft - iR
3.Well the(checliWell use).; . a7-SCREEN . ..
Water Supply Well • -- Faust TO •DIAMMF.•O R' SIDI*M5 TIIICttNtyS 1tlATRRiai, .
68
ft.
CJAgtfculturar CJIvlunicipaLThbllic 81 'ft: 6 in NA NA Open Hole
•
' ®Geothelmat(ReatingICooling Supply) ®Residentiat-WVater Supply(single) it, it' I i
i 0
DludustrialiComntcrcial DResiderttiat Water,Supply(Sim. red) t-t9:GROUT ..,. •..•.,,-•: :_
FROM TO. MATERIAL i EMPLACEMENT METHOD&AN10UNT I
Cl Irrigation 0 'ft. 68 ft, Portland Tremie
Non-WaterSupply'Welt _ .. . . . .
' RIMonitoring •f:114co c --- - ft._ fl. _ .
Injection Welt: ft, .
r .
ClAgnifcrRcctiargc DDGti)uildrlatcf Rcnlediation 1,19iSAND1Git,,VEL"PACf{•filliuplieabthl"- -=- -_-- -- =4_'_�-
:FROM To MATERIAL t:s1PLACEMENtMETHOD -
❑Ailuifcr.Slorage and Rscevety [Salinity 13airicr R. It.
❑Agnifer Test. DStorniriatcr i3rainage ''
ft. ft.
CDE:tpetinicufal Teariotegr ' RSirbsictcncc.toutrol I'
211.DRtLLING'LOG(attach additional ilicctsif ncccssari•1• .. -
❑G;othtnnal(Closed Loop) DTracer - FROM TO DESCR1PT1O:ti{canlnMnca.ei:tAntektrot...rain we.dui
. DCr.3tltltennal(IIcatineiCaollneRerurn) D011ter(explain touter.#2 t Remarks) it• f
ft. ft.
- - Date Well(s)Completed: 11/22/23 :Well iD#DMW-1 _ _
• ft: ft,
Sa,Wedl Location:
• Sheetz ft. ft I v�"i~�
Feed ty,!OrstxrNamc Facility IDk�'ifappli:able) R. p. RI l 1 n
12290 NC Hwy 150, Winston-Salem, NC, 27127 ft.' ft. ' 1V��
•
Pibsical-Mdress.City.aixt Zip . . lrf;vl 1% -. .r• -
21�HEM1tAEtfGS-';,. � ��=�R1I tEc.q
• Forsyth . Open hole well .... .3
Camay Parcel Itteatif=tIon No.(PRI)
5h,,iaititndcaril Longitude in acgrccs/mitinutcs/secondsUrdccititi!cirgrccs: -22,CerIifiration:
Om ell field,urge latiloug ig so:Mekid)
N W Y'' -_ -- -------' 11/30/2023
Signature ,:r%. ' 'r r �.—..-_-.
.�„Ja li i.Y.�L::i:�-`--- Date
G.ie(.ire)WC R'el(9)t xFenllanettt or I7Tentporn-% 11r.rdgnvik chit fain, R( ;flu a,..Z:4:, i,As.,...strRYoilesesi Lr,aveordirnce
with FM NCAC OW -.---.~-l'::,:.i.. .aG,010?fl(1 Conslrrt r(on Standards and rlirr a
7.Is this a rt:pair to an ekistin„Welk DDYcs-,or- WINO rcrprofrhds rrcorrl hr s•ireen provided ra'UT.rid miller. •
If 114::is o ripe r.fall our krr(arzi uellcarurrucr(ori 1ip'urosardon imrloijdaln the rurnxe of the I'
itipmirunder 0?1 reenarks..secadan ar w the back of this/Drop. -23:Stte.tliatgrenr or additional well d
etails: •
You may use the hack of this page to pros'ide additional well site details or Well
S:Number of Welts constructed: 1 construction details. You May also"allachaddilibual pages if necessary_
For ritakdple.lrjeerlon or mooruaater supply wehlt ONLY with the srtmecuns(rusiou,you rcua
sa6ntit ow form.' SITBNIITTAL iNSTITCTIONS
9.Total Well depth below land surface: 81 - (fi.) 24a. For All WORK.: Submit dli$farm within 31) ilayS of completion of well
For nrokdpfc wrflrlfsrall depths hidifterent(e•.rrmp e-@200'and.2@ 100 construction to the fotfowiug: ;,
1t1.Static water level below top of easing: (Ft.) Iliv'isii r of Water Rcknurces,Infornintipn(Processing Unit,
if heater tree/is afire maw,ills"t" 1617 ALtil.Scrs ice CiI enter,Raleigh,NC.2 7699-I617
L1,Borehole diametcr112,25"/6" (in.) tab.Far infection}Neill ONLY j In addition to sending the fomt to the address in
24aabove.also subunit a copy
1 of this faun within 30 days-of completion of wwll
2.'Well construction method:Auger/Air cottsuuctiart to'-the folloWingl.
(Lc,angec iatary,cable.direct gush.e(c.J 1
Division of Water Resources,Underground Injection Control Prilgrant,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-I636
13;n,Nie1uY( im) Method of test: 24e.For Water Supply&Injection Wells:
Also subunit one-cbpy of this DAM;within 30 days ofcbuipletion of
flab:Disinfection Wpm Amount: mil constmction to the county h'calth department of the,county where
constituted.
Fans GALL North Carolina Department ofEtwiramnetn awl Natural Resources-Division of Water Ro oLrom Revised August 2013