HomeMy WebLinkAboutGW1--05085_Well Construction - GW1_20240827 t.
II
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be wed for singk or multipk,rcils
1.Well Contractor Information:
ftINMOUtMONIES
Chris Ruffer FaOM TO OFtiCRtnntN
Wcll Cotir. for Nark ft, ft,
4223-A ft, ft.
NC Wdl Contractor Certification Number 15,OUTER CASING(for nuhi ea+rd Welk)Oft LAYER Of
rarAI TO DIAMETER THICKNESS MATTatAI
sAEDACCo n. rt. in.
Colman Nana IA INNER('.AIING OR 1T61Nl.ignotherfal t•Ine4 at)
FROrt It) in rrlV 11 i TIOCAxESS MATERIAL
2,Well Conatnaction Permit it: 0 ft. 1 42 fi. 2 i+. SCH-40 PVC
Lin all applir able well prtmitr fi.r.County-State,Variance byecO 'f eer.i
fi. M.
3.Well Lie(cheek well esei: I'.SCULL
Wider Supply Well: FROM tv DIAMETER sr,OTSI77 TNICKI4R.T3 1 MATR*IAI.
42 ft. 57 R 2 16• .010 SCH-40 ' PVC
f_t AgncuIural ❑Municipal:AtblIc
I IGeothemtal INeating,Cooling Supply) ❑Residential Water Supply Isinglcf
I fr. It. is
I i lndmstriatrComnsercial ❑Residcnnal Water Stipph-Ishared 1 IR GROUT
FROM TO MATERIAL. EMPLACEMENT MET1100 A AMOUNT
Glrneitton 0 ft. 38 ft. Portland Pour
Non-Wider Soppy Well: R.
(E Molutonnl; GR eco\cry I
Injection Will: n. n
G Aquifer Recharge ClCiroandwaterRenxdcrnon If..SANl1GRAY[L PACE(If applicable)— i
FROM TO M A I I Ki%i EMM.ACFMENT METRO!) •
ID Aquifer Storage and Recover) ❑Salinity Hamer ; 40 ft. 57 ft. Sand *2
❑Aquifer Test ❑Stommraicr Drainage
ft, ft,
❑Espcnntcutal Technology. GSribsidcncc Control
20,DRILUNG LOG lathed additional Ikeda if merman I
❑Geotltennal(Closed Loupi ❑Tracer Mod TO DESCRIPTION'tuts,i.rd.r«.w.a,..k Nor.pr..mr•.rtr
❑Geothennal el lcatingtCooling Return) ❑Other(explain under On Reatattsl ft. ft.
ft. ft.
4.Date Weiltrt Completed: 7-16-24 Well IDaMW-1 IL R.
5a.Well Location: R. ft.
Lee's Grocery U. ft 1 a`N..-`. . V 1—
f.:,br. U..,.:r`..:r.. Fai,6tr If)krifapplicable) R. B. AUG �J
4609 N. Cherry St., Winston-Salem, NC, 27105 ft. AG rt. 2 7 2024
Plnsical Aditcss Cit):.and Zip
it mums ,,�(5S,, g'S.cf l n^^^ +u.
Forsyth Bentonite seal from 38-
Forsyth
CYiX4'-t v
4o tit,t, Parcel Identification No IPINI
5b.Latitude and Longitude in dcgrrea/mirwt:es/seennds or decimal degrees: ,. (-0.,ifir:ltir,n:
(ifwdl!kid mac IA long r.adllcl:ntt
N „ Chris Ruffer 8/11/24
Stgwt, •I Centbcd Well Connecter Dane
6.Is(are)the Asellls): SlPennatfent or ❑Teelporan Hy tignaix Air krne.I hereby certify that the*elk%t ow(*reef caeasrrm red to acorrkm.e.
with 154 NCAC 02C.O1f0 or 15A NCAC 02C.0200 Welt ConsNnttioo Stu/Wards anti rho e
7.Is this a repair to an exists well: Dyes or 19 No rape n'chit wan!has hero provide!to the awl!owner.
110.0 is a repair.fill oral aroma urn r rei$tna Tien Nrfarr wkw are!a rpkwi the earner of rho
repair ord.-TV!remark.,section or OM the bail of fhb form. 23.Site diagram or additional well details:
You mar use the back of this paw to pros aide additional well site details or well
8.Number of welb constructed: 1 constriction details, You may also attach additional pages if nccessan.
for muirrtdr,air,roes on.nrAt.werrr rupph wells ONLY was rho sow conatnretie•r ..0.or,
selbnir<Ynr fora,. SI I BM ITTAI INSTUCTIONS
9.Total well depth below land surface 57 (fru lit. For All Wahl: Submit this form within 10 dars of completion of nell
F. .,,, .,rU,for:df d.'pd,•,,.,rrli•re•nt rrrumrptr- ib'?EMT rind 2k'loin conatnletian to the following—
Ill.Static water lead barn trip of casing: (ft.) Division of Water Resources,Information Processing Cud.
If ratter Jere!n above rasing.u 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter:8.25" _Oa.) 24b.For Injection W'elb ONLY: In addition to sending Qte form to the address in
24a abor e. also submit a copy of this form within l0 days of completion of hell
12.Well eonitrintiln method: NSA construction to the following.
(I e.auger.Erman.cahIc.direct push etc.)
Dia talon of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: IhJ6 Mail Semite Center.Raleigh.NC 27699-lit ib
I3a tilcld IEPmI Method Rtresr tic.For Water Suppir&Injection Wells:
Also submit one com of this form within )O daysot completion of
136.Disinfection hpe: Amount: , well constriction to the count!, m�heahh deportment of the com Where
constructed
Fong GW-1 Mont Catalano Ikpammo n of Emmons:o and Natural Resources--Uri n u,n of water Rmot,ces Re,tsed.August?I11 I