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Home My WebLink AboutGW1-2022-05598_Well Construction - GW1_20220614 Print Form WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only: 1.Well Contractor Information: Chris King 14.WATER ZONES Well Contractor Name FROM To DESCRWTION 2080-A Z S 2z It. OCR; t F, Ct tt NC Well Contractor Certification Number 15.OUTER CASING for tnnitig d wells OR LINER if a ticable Aqua Drill, Inc. FROM TO DIAMETER TWME88I MATERIAL ft. tt 19,' in. / f I t G Company Name 7 /f �/�\ _ 16.INNER CASING OR TUBING eottiermal closed-loo 2.Well Construction Permit#:A.A— �+-& AAt 142 -401 C),5 1 FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits Le.UIC,County,State,Variance,etc) k• ft. in. 3.Well Use(check well use): ft. ft in. Water Supply Well: 17.SCREEN FROM TO DIAMETER SLOT SIZE TTirCKNFSS MATERIAL Agricultural OMunicipal/Public g g in. Geothermal(Heating/Cooling Supply) Residential Water Supply(Single) fL ft Industrial/Commercial DResidential Water Supply(shared) 18.GROUT Irrigation FROM '1'O MATERIAL EMPLACEMENT METHOD&AMOUNT Non Water Supply Well: ft. ft .� Monitoring 'Recov�'Y ft. } l2 i� k. Injection Well: ft. ft. Aquifer Recharge Groundwater Remediation Aquifer Storage and Recovery [)Salinity Barrier Bier 19:SAND/GRAVEL PACK if applicable) IJ' FROM TO MATERIAL EMPLACEMENT METHOD _ Aquifer Test �Stormwater Drainage ft. ft :)Experimental Technology Subsidence Control ft ft Geothermal(Closed Loop) OTracer 20.DRILLIi G LOG attach additional sheets if necessary) ,'Geothermal(Heating/Cooling Return) __. Other(explain under#21 Remarks) FROM To DESC--R''IP f ON color,bard—,soit/mck rain size,etc. ft. <K ft. C�7 C 14 4.Date Well(s)Completed: �'��!y—W 11 ED# ft. ft. irVGt �� 5a.Well Location: q0 ft. -tt No 'o, C - W� ft. ft Facility/OwnerNam�ee �/ Facility `ED#(if applicable) ft ft l f�f`a� +� °li ft. ft. JUN 1 Physical Address,City,and Zip ft. ft CMy l G>t C.[ti 21.REMARKS I County Parcel Identification No.(PIN) t' Ccic7irdt7 UN 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Certification: w'//� �] TV W 6.Is(are)the well(s)t-manent or OTemporary Signature of Certified Well Contractor Date ,,{ By signing Mkv form,I hereby certify that the well(s)was(were)constructed in accordance 7.Is this a repair to an_existing well: OYes or.- o with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a If this is a repair,fill out known well construction information a'n-d'es\p(ain Use nature ojthe copy of this record has been provided to the well owner. repair under#21 remarks section or on the back ojthis form. 23.Site diagram or additional well details: 8.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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. drilled: SUBMTFTAL INSTRUCTIONS 9.Total well depth below land surface: ( )For 24a. For All Wells: Submit this!form within 30 days of completion of well multiple wells list all depths if different(example-3@120t0'and 2@700� construction to the following: 10.Stalk water level below tap of rasing: `1 (ft.) Division of Water Resources,Information Processing Unit, Ifrvater(ever is above casing,use"+/•� 1617 Mail Service Center,Raleigh,NC 27699-1617 1l.Borehole diameter: b (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a 12.Well construction method:AU �Z t > 1 1 above,also submit one copy of this form within 30 days of completion of well (i.e.auger,rotary,cable,direct pusb,etc.) construction to the following: FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) Method of test- + 24c.For Water Supply&Iniection Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type:. Amount: -2- completion of well construction to',the county health department of the county where constructed. Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22_2016 GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH Division of Environmental Health,Water Quality Unit 400 W.Market St.,Suite 300, Greensboro,NC 27401 Record of Construction, Repair, or Abandonment of a Well Address of Well: -5-2 36 t�cA4 54 S A cj lied A )e ry e LATITUDE 3_ Well Permit Number:22-nz -/ .,j rj H i? - m:S 7 LONGITUDE Well Contractor Company: P� Completion Date: 30 -2 2— Total Well Depth: 2 `1 $ ft. Well Yield: l 0 Q gpm Static Water Level: L_ / 0 ft. Outer Casing Material: t iZ? I p J. Formation Log Casing Diameter. in. Casing Depth: (4 6_ft. Depth Description From: 0 ft. To: f6 ft. e e d C )A-,l Inner Casing Material: From: ft.To:'�- a ft.. S rud Z Casing Diameter: in. Casing Depth: ft. From:L16 ft. To:2,60�Eft. Y?7VI4 If From: ft. To: ft. Grout From: ft. To: ft. Depth Material Method From: ft. To: ft. From: U ft.ToLO ft. -� + From: ft. To: ft. From: ft.To: ft. From: ft. To: ft. From: ft.To: ft. From: ft. To: ft. Water Production Zones Depth: 2 i- _ft. ft. ft. ft. ft. ft. ft. Yield: j j Q gpm gpm gpm gpm gpm gpm gpm Method of Repair: Method of Abandonment: I hereby certify that this well was constructed,repaired,or abandoned according to,the Guilford County Well Rules in effect on•this date and that a copy of this record has been provided to the well owner. ��)-;4- Date: �� 3� Well Contractor: Certification#: O:� low Record of Pump Installation Pump Installation Company:—�--�'`� , " Completion Date: P'�;i Pump Depth: I C)C)_ft. Static Water Level: ft. Pump Brand: Pump Size and Rating: 3141�hp / 1 gpm I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well Rules in effect on th' ate d that a copy of his record has been provided to the well owner. Well Contractor: Certification#: Date: f l Z 2 Revised:January 1,2009