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Home My WebLink AboutGW1-2022-06347_Well Construction - GW1_20220705 Print Form. WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: Chris King 14:WATER-ZONES , Well Contractor Name FROM TO DESCRIPTION 2080-A —7G� 76' d 5 G l lit tt ft. NC Well Contractor Certification Number I&OUTER CASING focmulti-case&wells ORLINER da livable Aqua Drill, Inc. FROM I TO DIAMETER Company Name TIDCKNESS MATERIAL ft. ft. 6 °' �uIZ2 � i ^� Q�� 16ANNERCASINGORTUBING: eothetmalclosed-loo 2.Well Construction Permit#:r1`� l l I�N Z-0 2 {09 FROM TO DIAMETER TffiCKNESS ` MATERIAL List all applicable well costruction permits r.e.UIC County,State Variance,eta) ft• ft in. 3.Well Use(check well use): ft- ft in. Water Supply Well: 1Z SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural Municipal/Public ft ft. is Geothermal(Heating/Cooling Supply) psidential Water Supply(single) fL ft. is IndustriaUCornmercial OResidential Water Supply(shared) :18.GROUT, Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: fL ft Monitoring ORecovery % it ction Well: Aquifer Recharge OGroundwater Remediation ft. ft. 19.SAND/GRAVEL PACK(if a'livable 'Aquifer Storage and Recovery OSalinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD -_ Aquifer Test [3 StormwaterDrainage ft ft• Experimental Technology OSubsidence Control fL f. Geothermal(Closed hoop) OTracer r20.DRILLING.LOG attach additional sheets ifnec " )': , Geothermal(Heating/Cooling Retum). MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soir/rock type,gmin size,etc.) 4.Date Well(s)Completed: p ID# fL ft. 5a.Well Location: it ft ft ft. Facility/Owner Name �,y ( applicable) ft. ft Facility lID# if livable ice•+'e'^p F y ��B S, �Z �i�rz (r trl� i 4 i��C'Y1dSG`y'Z R fL ,• _ n. Physical Address,City,and Zip ft ft. 21-REMARKS County Parcel Identification No.(PIN) izu„I1,•:: +1't1A Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: W`,i-'t.;: fiti1� +\'J i i�ill',iLc7V°:+�i Cii 0 I (if well field,one W/long is sufficient) 22.Certifiea'on: N W Xz ^ Cl `.22 6.Is(are)the well(s)*ermanent or OTemporary Signature of Certified Well Contractor Date By signing this form,I hereby cert jj•that the wells)was(were)constructed in accordance 7.Is this a repair to an existing well: Ayes or ON. with 15ANCAC 02C.0100 or 15A NCAC 02C.0200{frail Construction Standards and that a If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner. repair under#21 remarks section or on the back of t1dyform. 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. drilled: r SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: / (ft) 24a.For All Wells: Submit this form within 30 days of completion of well For muluple wells list all depths if different(example-3Qa 200'and 2Q100) construction to the following: 10.Static water level below top of casing: c 0 (ft) Division of Water Resources,Information Processing Unit, Ifwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617 11.BorehoIe diameter: t�(m.) 24b.For Injection Wells: In addition to sending the form to the address in 24a 12.Well construction method: 1�l L fZ y above,also submit one copy of this form within 30 days of completion of well construction to the followin - (i.e.auger,rotary,cable,direct push,etc,) g Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) �t� Method of test- S c Q h -I-- 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: (`� 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 i GUII.,FORD 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 Abandonm> e'nt of a Well Address of Well: '90) A 5KC LZ PA 17 K d i►Z c_ LATITUDE 3 Well Permit Number:12 -O L) &-%041Z-0j,2"'Y0!R LONGITUDE Well Contractor Company: Pv4,i s C,. .��l ti ,-1- -• Completion Date: 2�, Total Well Depth: ft, Well Yield: 6a gpm Static Water Level: ft. Outer using Material: Formation Log Casing Diameter: in. Casing Depth; ft. Depth Descrip 'on From.-2 S&t.To:7�ft. I G oZ Am Inner Casing Material: S E>iZ 2 1 From: ft_To: ft. Casing Diameter•'X _in. Casing Depth: ft. From: ft.To: ft. From: ft. To: ft. Grout From: ft. To: ft: Depth Material Method From: ft To: ft. From: ft.To:-L ft. From: ft.To- ft. From:—ft To: ft. From: ft. To: ft. From-.___ft.To: ft. From: ft.To, ft. I Water Production Zones Depth: Zd-.57ft. ft. ft. ft. ft. ft. ft. Yield: /S O gpm gpm gpm gpm gpm gpm gpm i Method of Repair: aZ� ) �C�. 1� r LZ Method of Abandonment: I i I hereby certify that this well was constructed,repaired,or abandoned according to the Guilford County Wel! Rules in effect on•this date and that a copy of this record has been provided to the well owner. Well Contractor: Certification#: a 0'(,-D--A` Date: 0 Record of Pump Installation Installation Company: - �` �- -� Pump p y= , -v Co PPletion Date: ;,q t a, Pump Depth: �' ft. Static Water Level: ft Pump Brand: re-_ Pump Size and Rating: C r 5 hp gpm I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well Rules in effect on this date and that la copy of this record has been provided to the we]I owner. Well Contractor: -�/ � Certification 4P ZZ y Date: Revised:January 1,2009 "�