GW1--01294_Well Construction - GW1_20240229

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WELL CONSTRUCTION RECORD FM-Jut-cavil ITsc!MIN:
Ilis form can bc uscd fat Magic tir tnultipk was•- -
1.Well.COntraCtomt Information:
-;111-WATER ZONES
Stefan Smith FROM TO DESCRIMION '
WCii Connactot,NaniC ' ' •ft. ft..
3576A . . ft.
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- 115-."MITER CASING Nor muttkisedruitis;OR (ififii ticalikf-
NC Well Contractor Ccnificatinii Muth&
SKIM •To , DIAMETER. THICKNESS MATERIAL.
SAEDACCO 0 ,ft.• 18 it,. 2 ,.hi. SCH-4 0 • PVC.
Company Name 16:INNER CASING OR.TURING itimilicraialetawd4non)....
FROM TO ,..DIAMETER HIICKNESS MATERIAL
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2.Well Construction FerMit 4: . 'ft. . ft. ,-ta.
rims' nuaRi'tkotleiwirpehrtiiz fir.caiffiry:Stirie;Vakiantse.Ilecticf;rit) . .
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. it.. IL.• ; in' •
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3.Welk Use(thcek.Wye uSei: rt.S(:ttEtN
Water Supply Welft - • Fuoio. TO - •latAlitsTER SLOT Sirs: -TIIICWIOSS 1•IttATittuAt,
, 18 R. 28 It; 2 - ilit. -.010 SCH-40 PVC"
ClAgrieultutal EIMUnidipatiPuldie .
-r4 im.
OGeothennal eleatingtooling Supply) E3Residential Water Supply(single) :
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in lndustriallConinteral C2 eiResidential Water to.GROlIT Supply(shated) ...ijom . .16.. . •- i.k. -. EMPLACEMENT METHOD&AMOUNT
14 ' '11. Portland Pour
Nott-NViter Sup ply Welk.. . . .
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.6. . . • •
1,,ionitpring. . • . . ' nit•ccovoy . '
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Inject lonWelft • rt. . O.
CIAMtiferPechtirgi - • . 130roundwater ReinallatiOn •to."SAND/GRAVELPACK Or anothmttlei- . .. .... .
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FRONT- • TO• ' • - MATERIAL • ' EMPLACEMENT Mrnion
ClAnufrei.Sionige arid itcCes-C4^ 121Salinity Baidei • 16 . ft:. 28 - ft. Sand ; •2
13. tniiirci-tcst. OStinnavatcfOri4itiV. '
rt., --0.
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CiE*eriment6.1Technolo&v 1.3Subsidence•-tonitai
• 2o.DRIL LING"LOG'fittacluiddi timid!dials-if accessary)
• "1:1Grotlignuat(Closeti Loop) ' CITracer: . -.IntoNt- -to . . DESCntritON Noun.intnincti.suilAnekIHrt.'orift I 'rim W.)
• OGtothettnal(Reatinatooline Return) : 130ther(explain under.g21RettiatitS) .° 'ft. •30
ft.. rt. Silt
4 Bate Weft(s)Competed: 1-1'8-24 Wen Meif-3 ri c C,f-.:i.vEr.).
5a.Wel1.1,0eation:" .
ft-. . ft.. .
Thruway Shopping Center . ft; - St, • - - FEB 2 0 Z024
Ricility,Divm-Rtunc. . - Facility IDN(it appir.abic).
ft.- • ft.-- '- " Iftforinatien pr-•;,,,,
296 S. Stratford Rd. Winston Salem, NC 27103 Forsy, R. It.
"-:• .-ii"..zi Wily
Winston-Salem, NC, 27103 PIO-tidal AO*citk-nbl 2IP' -',2L.:nERIARRS-
Forsyth ,
- . .2 foot bentonite.seal from 14 to 16 feet.
County Farce]ItIciiiincalinn No,MINT
511.Laiiiiidc'and 1.-Ungitude in et dcgrcesiminuteit.sCekinds nr decimal&tikes': 22.Cerlifleation:•-. ' .UM&K.oat taltlotii$sidTicictin . . .. . . .
• .47;/'
36.093000. . . N 80.282891 • 4 .'i ' • - - • i. '
w. ..„...- , 4_,..„, .t- • . 1/26/2024
cfCcIZII-V-ell Gann:mai. ' .-Dge
6.Is 044 aite.well(s): X1Perinaitent .or ElTemporary Sy signhtg tkir.../atrir;1 lrercty drag&Ow ilw iiv.1101 os Dit., ex/mime:of&accorthrqce'
with 15A iVCAC 02C,0100.or 15A NCAdO2C,0200 Weil Comerrierion SNiVanis widths:a
7,Li this a repair 16 an existing well ICIYes or Si% IrsOyOf ash rrford?los Nall-if-91*W Ira di:e Itril eltqler,
/MI5:a a repair.fill Oaf kruini well 614571UCI190 Inform-akar and rylala she maare of the
repairturderE21 icniarks'irciiiin or ixn d ,1 u bad 6day form. 23.Site diagram or additional well details:
You may.use the back of this page to prosprovide additional well site details' or Weil
8.Nuntherof wells Consinteted: 1 • mustn't:don-detail: You May also atlachadditinnal pages if necesuity.
Far malfiple kyeerion or ampltger i suppl.i.welts ONLY with de same eansiraidlon,yirm AM r •
=Oar oar farra. ' SUBMITTAL INSTUCTIONS
9.Total WeRdcpth herowlatid sutface: 28 . (II.) 24a. For Au Wells:.-Subthit this Tam Within-30(lays uf"completinn of Well
Far maniple wet I s&rail depths if diRiy,IVII(e.mapte-3@204rami 20 100) - tln.stnictimitollicToItactinT.
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la.Steep water level below top'of cmslIngt•17 .(f) Diviiiun of Water Reitouregls,Information Protessing Unit,
If wryer level If'dare casks;ase"+" 1617 Atall'Serriee Cen '
ter Raleigh,NC 276994617
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11.Borehole diainctem 8-23" - • '(in.) 24b.For figment;WON ONLY: in addition to sending-the fown to the address-in
• .24a above.'also.submit a copy of thistrfonn within 30 days-of completion of well.
12.Well cbusirttetion'Method:lisA constmetion to the foiloWing:
tic.nag%minty,Cable.(End iMsh.Mt.}
' Division of Water Resources,Underground Inliciion-Control Program;
FOR WATER SUPPLY wimp'OM.Y: 1636 Mail Service Ceittr,Raleigh,NC 27699-1636
2-te.-Fnr Water Simply&Injection Wells:
13a.Yield(gPm) Method of test:
• Also submit one copy'of'thiS ftiint Within 30.days of Completion of
13h.Disinfection tiper. Amount: • -wcil iconstniction to the county hcaltft department of Me count.where
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•FanuGW.I. NorthCaratina Dcptuution of EM1101411CILtaitd Natural ItCscurccs-Riviiion otWalcrEZattrrtS Revisal Angus:tall-I
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