GW1-2021-01029_Well Construction - GW1_20210305

SPELL CONSTR.IICITON RECORD(GW-1) Forint anatUse Only:
1./Well
Contractor Information: Z
Well CoonagorName HBOM TO n>6CRIPrfory
30364 ,/ ft. , R
R
NC wen(:mtractm Cerfi6eatim Number R 7
15.0DTRR..rASRVG
Yadkin Well Company Inc. mom nreasra
Compaay Name R'
((,� cG ;'I /, :Y6:1CII'tE8-C+k.ffi7G'OR'TQBB7G -
2.Well Construction Permit#:,r'-V O -est N N R- 0 3 9 7' )!Pond io nream'!D; 'rlIIr= . Ms'nuTaL ,
List aO cabl�well conaCadion peradu p.e lllC Crony,man;lr i 'etc) in tt / in. V
3.Well Use(check well use):
Water Supply Wen: '17.8f418ffi9' ._. .• , - . . ...
/ A collate! HBO% TO DLIEtSi'@t SLOTSlZB .,THI®V� aramnarar
� mlicipaYPublic U R m.
Ccothermal(HeatirdCooling Supply) �tevdemial Water Supply(single)
ft
Induurial/Commracial Residential Water Supply(shared) .. ...
.or HBtau >TD?- .1NGTJZBrdt.::• R>YrACfalOfrMCD3on&AM UNT
Non-Water Supply Well: p tt ft r • !mot
Monitoring C Ra a.el T
Injection Well: overy 3 R .23
y•
_ ft
^.gulfs,Recharge ©Groundwater Remediation R
Aquifer Storage and Recovery [USa(inity Barner .....
/ems AOE
HBOM To M TEPJAL j>aaracorIIel'Maason ..
--A4mfa Test �]Stormwater Drainage R R
Bxpeomental Technology Subsidence Control R
(3eothc®al(Closed Loop) OTracer 2MIDA A
^£v LOG.eutiek'iidnitiauel shes6 ifneress'. _ .....-
Geother al C 22L.Rg Retum) Offi-(explam under#21 Remmks) HBOM zn n>satWrloivtmmr bardaea.mahea a �,u�,ee..•
R R Spy
4.Date Well(s)Complete3 '7- h t well ID# (�-3 3 fL �r C�Q fL p e
Y w Ic
So.Well Location: Phone number .2 R ,r d� le (ate
f Vu@ /l'lrr f R R
Faeditylowac Name Facility M#(if;-w ieable) ft IL -
7902 le- ""Aet- C4. G(-one R fL
Physical Ad city.and zip
Co-ty Paul IdenuSemonNo.(PIN)
5b.Latitude and longitude in degrees/minutealseceuds or derdmsl degrees:
(¢well field one hddoog is suffe ei)
ZZ Certification:
.?c. 0 IQ N 79 - '�G , 728 W �J[/
]/7i�l�t�i �-
7- ,?�
6.Is(are)the well(s)�Permanent or Temporary 3f�n=ofCert�ed Well Canhac[or Dye
By signing rhrr form,I hereby ecng5,ohn the a-U(s)win(were).1w ded M acemdmrce
7.Is this a repair to an existing well: []Yes or �'Io w h I5A NCAC 02C.0700 e,15A NCAC 02C.0200]Yell C—"aion Smndordr and thm a
Ifthu is a mPc&,,fill out kaua udf-1b ton infarmmleeand esplala the namm of the copy offhu meard has beeaprovlded m the uell Owner.
raper wrier 021 ramarU.rreVm man the back oftMsforr
23.Site diagram or additional well details:
B.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this Page to provide additional well site details or well
construction,only 1 GW-1"naded Indicate TOTALNUMBER of wells construction details. You may also attach additional pages if necessary.
drilled
p 3� � H S[JBMICTALRVSTRIICTIONS
9.Total well depth below land surface-. ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
Formultiple weft,lbrolldepAs ifdrra (-Mple-3(a)700'aed2(a)100� construction to The following.
10.Static Water level below top of casing. 70 (ft) Division of Water Resources,Information Processing unit,
Ifwmerlwe!is obmw mswg.use"+" 1617 Man Service Center,Raleigh,NC 27699-1617
IL Borehole diameter: �': (m.) Bit Off
24b.For
��// • Injection Wells: In addition to sending the form to the address in 24a
12.Wen construction method:__ �e 1S7 y abOpe+also submit one copy of this form vnthm 30 days of completion of well
C.c-ger,mtu3%cshle.daatpuak eft) '7 construction to the following
Division of Water Resources,Underground Injection Control Program,
FOR WATER 6T)PPLY.WlSLLS ONLY,. ,,t 1636 Matz Service Center,Raleigh,NC 2 7 699-1 63 6
13s.Yield(gpm)_� Method of test q/r 24e For Water Supply&Injection Wells: In addition to sending the form to
136 Disinfection
type: HTH - CUPS (/Z the address(es) above, also submit one copy of this form within 30 days of
. Am n nnn cnmplebou of well construction to the county health department of the county
} TUC where constructed.
F.CFW-1 Nath Caroline Dc,.f ut of Ruyi.,,,.......t.
�.{�,� �y,��p� Quality-Division ofWyn Resource, Revi,ed2-22-y016
Date SlbL Y•„t& •2'• � .i6
:3st?

OWNERS NAME: BUILDERS NAME: I ICU C' fTa /+tee J
ADDRESS" ADDRESS: Z.JI!J414 Cr a& FCfin6�° CQ vz O.
MJ/\ripe (�G �YIICZ
PHONE# OFFICE#
Royer �andt 336 3!L - O l '7
CELL# vmowa 33C- 7ak- _L?<
COMPLETE IF INVOICE IS BILLED TO
Contractor
l }'6
I � J
S+7
MAywliq
To
yo

r t •
��0+`i♦Oi♦i♦i�i+i0=i
s � � `i`ii♦i`♦♦i♦i00i♦Oi�
O p, ♦ `."Oj� ♦•��ii�M..iO+iO♦O♦i0♦,O♦� i0� +'iFi +'�6e�'i♦.i♦�++�►ii ii0i,
>,��`��'♦ ♦�.♦ " '�♦ �i i♦'iJi'i'i'Oi♦i+i♦�i♦`i♦♦i'i♦i♦..��Oi 9p�+�♦.�♦��J���♦�♦�i ♦�♦� !♦�'
`'�'•s+ --=• _ ••-• ♦+'i� r� ►ii♦i+ii'i�ii'i♦Oi•♦' ♦i0�♦i+i+� . �...iiiii♦ �o•�!�i'ii
r'��i`.`i♦i'i`.� •• ' ♦+i i♦� O�ii�ii+i'�`i♦i►Oi♦♦Oi�i'i♦Oi♦i♦i♦i ♦�+�+i♦��`�•�+��•�•�Ost�,�.•�y
i`s�i` �ii�i�`���� `��i � 'i♦Oi`i+i�i0i♦i0 ♦♦,+i`i♦i�i�O�ss♦OiO�Oi`i♦ii♦♦`i'i♦�`�'�r'�`��,-
.`i`Oi�!i�i;��0� +♦OO i♦i♦i`Oi+i♦i♦i♦i0♦i♦i♦�y,0♦+i s♦i+i`ii<�ii♦OOi�♦♦♦♦,O♦`�
I� .O_♦. � `��N� uI��i♦i'i`i♦i+ii♦i+i`iO�Oi�+♦♦�i♦ii♦i+i♦♦'i``♦�+°��'A�aL..
i♦ +�o�ea+� r= ii'i+`♦'+i�:.�►� i�`a►�+�i+<:G�c�d�•�i® .

ORD Cop Environmental Health Division
W Water Quality Section
W110 400 W. Market St.
W Greensboro, NC 27401
[phone]
LTH a` ,
Permit to Construct a Well
Address: 7902 E GANDER CT, GREENSBORO, NC 27455 Permit Number: 14-08-WNHR-03945
Comments/Specifications:
Well shall be located and constructed according to North Carolina and to Guilford County rules.
Well site must meet minimum separation distances.
Above Information Certified By:\ Date: IZ R
Own r or Authorized Agent
Permit Issued: Date Issued:
EnvironmentaF f�eattFSpeciahst
1 certify that a grout inspection was completed and is in compliance with Guilford County Well Rules.
Partial Grout Inspection: Date:
Environmental Health Specialist
Final Grout Inspection: Date:
Environmental Health Specialist
Permits for the Construction of New Wells shall expire one year from date of issuance.
• All property lines and corners shall be clearly flagged prior to construction of the
well.
• All proposed structures shall be clearly flagged prior to construction of the well.
NewWellPermit
Page 1 of 2