GW1--04998_Well Construction - GW1_20240828

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WELL CONSTRUCTION RECORD For infernal Use ONLY:
nit,form can be ow()for cin6k or nnrltipk%.ells
I,%1d1 Contractor ltrfornutioi:
14.WATER ZONES
Chris Ruffer MOM TO Da:SCRIPTIO'1
W'c1I Core-actor N:mk fL R.
4223 A ft, R.
I
NC Well Contractor Ccmi1 al an Number
1 i.OUTER CASING tier erll�med wed OR LINER(if aulrlkaRk!
FROM TO DIAMETER TRRTC\TNS MSTTRI►I
R. II.
SAEDACCO ..
Carman,Nan. Ili,INNER CASING OR 711SING vithenral closed-Ivor)._
MOM - TO DIAMETER VIE AMENS MATERIAL
2.Well Construction Pcroait g: 2024-19-06-MW3-RWO 0 fi. ' 40 ft. 1 2 a'- SCH-40 PVC
bit ull applicable well pennies(i.e.Cnattc .Sao.,tttnnrn r injection rte.( - <
re. ft. C.
3.Well 1 w tchct•k well auk It.SCRLLN -
Water Supply Well: FROM . TO DIR.IVTER MOT MU TNKKiMRis MATERIA1.
I-I Agricultural DMrnwipal,Public 40 ft. 50 IL 2 ilkO10 SCH-40 PVC
I ICeothemral(Heating,'Cooling Supply) DResidential Water Supply(singlet R. ft. Ia.
I IIrtdustria(Comnicrcial DRcsidctuial WaterStupph Igo" IL �
PROM TO MATERIAL ' EMPLACEMENT METHOD A AMOUNT
❑hngation 0 ft. 36 ft. Portland Pour
Aide-Water Supply Well:
R. fL
EMonitonng ❑Recover•
injection Wctl: ft. ft.
❑Aquifer Recharge CDCmrtudwatcr Remcdiation I .SANWGRAVEL FACE(lI applicable)
FROM 1 TO MATPRRRI. EMPLACEMENT mrnmoD
°Aquifer Stonigc and Recovcn °Salinity flamer 38 R. 50 ft. Sand #2
❑Aquifer Test DStonuwater Drainage R. I ft.
DEspcnnicntal Tcehnolog\ OSehsickrcc('olarol 1
21.DRILUNG LOG troth addidosal Ards if mason)
OGeotentul(Closed Loup 1 ❑Tracer PMow TO , DEscRIPTION,r.am.Ynrtinew.warMlrN pr.train AN.llr.)
❑GcothennaltHeatitrg'C•uolitlgReturn) °Other(explain undo a Remark
`IRemas) R. R.
ft. it.
4.Date W'ell(%)Completed: 7-23-2024 Wd11DITMW-10D f( See Gap' Notes if'
` `
Sa.W'ell Location: _. R. ft. t• r•r
Sherwin Williams R. ft. AUG 2 S 2O14
i:•,,I Facility ID,rifappli:abkl —�
fl.� R.
113 Old Stage Coach Trail, Greensboro, NC, 27409 m ft. ,.,. s,.
Piscwat 4dlrrs',I:its-and Zip I'2i.REM IRKS
Guilford I Bentonite seal from 36-38'
Comb, ... P.nce]I&illificnrnii N. IPIN.1
Sb.Latitude and Longitude in iks;rccslminutnisecnnds or decimal dt•Arecs: ,s.(,.tuitu iii<In.
Qfwel)field rile Ia6lnng I.-adii k'1311
N Chris Ruffer 7/26/2024
Sigrut, '1 Ccmfrcd Well Contractor Dale
6.Is(are)the wellts): IDPennanent ur OTeaporar}'
M ti>;n.,i.•this form.f herein certify obey the nrUds!was(Herr){'nrLYfNe'ICC in alY'OI%dar.Y
i.ut 15.4 NCAC 02C.0/00 or 1 SA NCAC(CC.0200 14'4 Cortaro,eon Staaiareb and that o
7.la this a repair to an existing well: JYta or 111Nu cops n(fhia record has brrn ivurided n,lb,11r1 owner.
iff Nria u a'Wok.fill nor bwwe well s oor naTiern infermarnnt.owl r.i.4snt Ow soirees 4 der
repair older I2i r-marl.%mme,,or on the bark of this form. 23.Site diagram or additional well details:
You may use the back of this page to prosaic:ddiuoiutl well site details or well
S.Number of well coRItrRcted: 1 cottsinrction details. You may also attach additional pages if trecessan.
for melnple inicarr n.n rise-..ntc,tupp/F wells ONLY waft flit ialoe rrwoarrlrritw i.e<On
rslanir one film+. Si IRM ITTA t JN.STUCTIONS
'I.Total well depth helm land su faoa 50 (ry.) 24a. For All Wells.: Subnnt this form iuthin III dais of contpldiolu of Dell
o.Ihrpir..ref,h.r,.ir 4l,aces•,.i•it Arrest fe.imnpfr-? 200.and 20'!Ou ) conatmetian to the folk,ning
lit Static water lei el below top of'casing: (f•) Division of Water Resources,IrforRlation Processing l nit.
i.Malec keel et above ramok.air•. 1617 Mail Service('cuter,Raleigh,NC 27699-1617
I I.Borehole diameter.6" (in.) 24b.For Ink'etior Wells ONLY: In addition to sending the form to the address in
24a abut e. also submit a cops of this form within 10 dass of completion of well
12.Well construction method:Sonic censltuction to the following.
ti e.auger.%Man.cable.direct push.etc.►
Ibisision of Water Resources.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I636 Mail Seri ice Center.Raleigh.NC 2769h-1636
Loa Yield(epnlI Mathrd r/ 24e.For W WW1 Nuppli at.Injection %ells:
Also submit one cops of this funs is Ellin to dais of completion of
1 Ih.Disinfection type; AEU well construction to the counts health deportment of the counts whets
comma:Ad
Fong GW-1 sons(atulttw L)epernnrtu Of Eits tnaurciu MA Natural Resorroea-Diowion of\Pater Rtnotrea Ra tied August 3,1 1