GW1--03839_Well Construction - GW1_20240628

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A
WELL CONSTRUCTION RECORD For Internal Use ONLY:
Tim loon,:an he liwil ftw single or multiple%sells
I,Well Contractor Information:
iltwAinutzwas
John Eisenman Ir110901 TO DIP:SCRIPTIO%
Well ConlInlete4 Name ft, ft.
R.
4439 ft.
IS.OUTER CASING Mir ouni-aned wells)OR LINER(W likable)
NC WelIConitactor Cciiification Nitrite!
FROM to i 1)14%11'7FR TTIKANTNS MCITIlltAl
IS.
It. ti. 1
SAEDACCO 1
('illioun Name Its INNER CASING OR 11111ING urethanes,elused-toor) _
VitOM TO : DIAMETER TIM ANEN's 'RI!VIAL
2.14'411 Constreetion Permit ft: 0 ft. 35 fi. 2 in. SCH-40 PVC
/au u11 applirahle writ pennits(rr.County.State Variance.!geni(Il el,-., — ----,
It. ft. is.
3.Weil I'se ieheel:%sell use): meow* .
-
Water Supply.%ell: ntOM 70 DIAMIrTtli MOT seri III li t5 INs M%It-KIM.
35 Its 50 ft 2 lc .010 SCA-40 PVC
CI Agricultural OMunicifetkPublic _
la.
DGeothennal(HeatingiCooling Simply) OResidential Water Supply(single) IL ft
Il
I llodustrialitornmercial OResidential Water Supply(A L GROUTwed/ m 7 i„ stsTERtst. EMPLAt I MINT NIE1I100 A AMOUNT
01rniation 0 ft. 30 ft. Portland Pour
Non-Water Supply-Well:
ft. It
Sktonitonng OR ccovety ,
Injection Well: It. rt.
, - _
°Aquifer Recharge OCiroundwater Rona:Ilion It SAND/GRAVIL PACK Of applkahlei
room I TO , si%IV in mu rson.survirst Mi-rnsin
°Aquifer Storage and Recovery °Salinity Harrier
33 It, 50 It. Sand 42
0 Aquifer Test OSIonmater Drainage .•
ft. ft.
IDExpenniental Technology 0Subsidence('out ml
26.MULLING LOG imbecile additional sheets if eccessars I
OGeothennal(Closed Loopi OTracet MOM TO DiNultIPI ION I tulor,lowIlite«,toitnwl.IN pAt.AAA*.1•14 440
OGtoilictinal(Heating:Cooling Return) °Other(explain under 021 Remarks) 0 ft. 50 ft. clay/sand
ft. ft. r- ..-.. .., ... ......
....• • ,'s i i._, :-....
4,Date Welfts I Completed: 6-12-24 well jp.1411-6R 1.‘Las%...•1....1 %., C Lii
IL ft.
54.Well Location: It. It. JUN 9 8 2024
.1 ,
Salem Spring Site ft. It.
r....d i• -1,,,,...:r`.-:I.. Fat:ilre, !De i if atiplicablet —
ft. ft. nv
It oki riZoitnu tt IC .1 UPte
,
303 Waughtown St., Winston-Salem, NC, 27127 H .. • ft.
P In ma I Ads:best,Citt.and Zip --2i.RI:NI Akio
Forsyth
Bentonite seal from 30-33'
_. —
to.a.h e.o....i Itkliillic,ilivi:Nu INN 1
5h.Latitude and Longitude in degrees/minutes/seconds or decimal degree= 22.Certification:
Of well fkld mic lationg is sonic ieia i
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N W - Z
....-
...-
6/17/2024
.., ---":-..--:--- . .
St isfirCa,diacti. -_.-
Dote
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6.Is tare)the swil(s): ICPentiattetit ,ir I:Temporary
By rignihg Air fdrhatite?"Vallir...r.5 7:r.f.:;111:4 was i.t7A)1YJft1IIIICICd arr accordance.
with I 5A NOW'OW.1.7.0.-.”1":.7::a7.4.-o-le.0200 Weil Colieremetio0 SuRadni,wki All 41
7.1s this a repair to an existing cell: 3Yes or ION° ropy f.l Oaf recon1 has hero prov4e4 to the well owner,
If Alai is iv rfprio.NI,,,,,r irmitii wen ten.fillIt Wel atfOrMalron NInd r%plum OW lkifirre of Mr
repair under 1,21 rrnherb Neviisnl or on the boa of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional ii ell site details or well
H.Number of wells constructed: 1 consiniction details. You ma also attach additional pages if necessary.
For muirrpir injection,,,,ti,v1,..,,,iret cupph wells ONLY with the same rimstritetion tou"to
Sabnur one form. Sit BM ITTAL INSTUCTIONS
9.Total well depth below lard surface: 50 (m) 24a. For All Wells: Submit this form within lo days of completion of well
For mmhtplr.v.111 lot oil depth,rf ftlftrrrill ir.Torriptr-.1•0100 and:?M'irwri constniction to the following
Iti.Static water testi below top of casing: (11.) Division of Water Resources,Information Processing l nit.
It.v.iier level ts above toting.ii, - . 1617 Mail Service Center,Raleigh,NC.27699-1617
II.Borehrik diameter:8•25" (in.) Llb.For!niceties Wells ONLY: hi addition to sending the(bun to the address in
24a abcn e. also submit a copy of this loon within 30 da)s of completion of %sell
12,Well construction method: HSA ioteituction to the following.
ii e.anger.rinan.cable.dinet NO.cue i
Dhbitsii of Water ReNiali rev..Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail SCCI ice(enter.Raleigh.NC 27699-1636
lk.For Water Snouts A.Injection Wells:
13A.Yield(gpni) Method of test:
Also submit One copy if-this Milo w itlini --,,) days of com f pletion o
III,.Disinfection tire: Amount: w m well consiction to thc counts licolth dcrvoriment of the county where
constnicted
Form GW-t North Carolina Depannrin of Ens tronmem and Natural Resources-Divaloo of Water R4501/CIES Res ised August lilt-3