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Home My WebLink AboutGW1-2022-06616_Well Construction - GW1_20220711 I ^: Print Forrn r WELL CONSTRUCTION RECORD(GW 1) For Intemal Use Only: j 1.Well Contractor Information: Chris King 14.WATER`ZONES, t.t. FROM TO DESCRIPTION Well Contractor Name 2 2) ft. J ft. I if, 2080-A { ft, ft. NC Well Contractor Certification Number 15:OUTER CASING:(for:multi-casedwells)'OR-LINER'd a "licable Aqua Drill, Inc. FROM To I DL04MR THICIINESS MATERIAL 0ft- � "L / I. 50TZ11 Company Name f} 16rTNNER'CASING<OR:TUBING. cdtbeiriial'closeddoo ''�.. - 2.Well Construction Permit# 1 V �- !VI YP J -f EROM TO DIAMETER THICENESS MATERIAL. List all applicable wit construction permits r:a."WC,County,State Variance,etc.) ft• f, in. 3.Well Use(check well use): fL % in. Water Supply Weil: pP y S .-FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural OMunicipal/Public ft. ft in. Geothermal(Heating/Cooling Supply) fjkesidenti.1 Water Supply(single) ft ft, in, Industdal/Commercial DResidential Water Supply(shared) 18t-.GROUT, Ilri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: (� ft �} ft• �pbl ZuG Monitoring � Recovery ft ft f Injection Well: ft. ft Aquifer Recharge Groundwater Remediation 19.'SAND/GRAVEL PACK ifa ll able . E Aquifer Storage and Recovery OSaliuity Barrier FROM To MATERIAL EMPLACEMENT METHOD Aquifer Test 13Stomiwater Drainage ft. ft Experimental Technology E]Subsidence Control ft. ft. Geothermal,(ClosedLoop) E)Traoet il 30::DRHJMGLOG.attaeWadditionalsheetslfuecess '' Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) rVROKTo DESCRU liON color,hardness soWrock a gain sis etc) 4.Date Wells)Completed: Well ID# ft. Paiz)! 1 ��Sa.Well Location: 3 4 1 U- 61 6f7 )t l'+5 t ft Facility/Owner Name Facility ID#(if applicable) it ft Nflr,��4 .'V , Physical Address,City,and Zip ft. ft 'i2f.REMARKS..' County Parcel Identification No.(PIN) 5b.Latitude'and longitude,in"degrees/minutes/seconds or decimal degrees: l�. ` e, �� DROCEJS212 U\I i (ifwell field,one lat/long is sufficient) 22.Certific tion: N W �'.Z 6.Is(are)the well(sermanent or ElTemporary Signature ofC rtifi Well Contractor !, Date I• By signing this form,I hereby cergo tlug,tiie wells)war(were)constructed in accordance 7.Is this a repair to an existing well• OYes onomo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well 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 tine ivell'owner. repair under#21 remarks section or on the back of thisform. 23.Site diagram or additional well I'de tails: 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 ifnecessary. drilled- ) � SUBMITTAL INSTRUCTIONS j 9.Total well depth below land surface.. �� `I'_� —(ft-) 24a. For All Wells: Submit this!form within 30 days of completion of well For multiple wills list all depths ifdii different(example-3Q200'and 2@1001 COnSirtiction to the following: � 10.Static water level below top of casing:: 40�'L (ft) Division of Water Resources,Information Processing Unit, If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: (in) 24b.For Infection Wells: In additiori to sending the form to the address in 24a J 7 above,also submit one copy of this form within 30 days of completion of well 12.Well construction method: A l/Z Cif�J,� construction to the following. (i-e.auge,rotary,cable,cable,directpush,etc.). Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cen i r,Raleigh,NC 27699-1636 13a.Yield(gpm) ✓ Method of test: 24c.For Water Supply&Iniecti In 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: h 0"� completion of well construction toj the county health department of the county where constiucteui. � Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 r GUILFORD COUNTY DEPARTMENT OF PUBLIC BEALTH Division of Environmental Health,Water Quality Unit 400 W.Market St.,Suite 300, Greensboro,NC 274011 Record of Construction, 'Rep ' or Abandonment of a Well Address of Well: W L! � `A C Gl.�s"sue/ � LATITUDE 3 Well Permit Number. 1 -� - 14IZ - 05`5 44 LOHGITUD We1I Contractor Company: �� ,-1-- , Completion Date: Total Well Depth: 3 `IS- ft. Well Yield: 5 gpm Static Water.I;evelc ft. Outer Casing Material: j7 ,2 1 Fortnatipa Log Casing Diameter: -in. Casing Depth: ft. Depth Description From:ZDL To:-6—lft. Sd i ) Inner Casing Material: From:6_ft.TO:,15-_!'ft _ //- SJa��vcl l��C . Casing Diameter. in. Casing Depth: ft. From: �ft.To- From- ft. To: Ift Grout From: ft.To: rft; Depth Material Method From: ft.To- ft From: iToZO ft. Iry - 79-'vC4' From: ft To: ft., From ft.To: ft. From: ft. To:____'L. From: ft.To.—ft. From: ft.To.—_ft.' Water Production Zones ft. fL ft, G ft. ft. Yield: gpm _ gpm gpm gpm —gpm " gPm gpm Method of Repair: I: Method of Abandonment: i. I hereby certify that this weIi was constructed,re a2r I!p ' ed,or abandoned according to the Guilford County Wolf Rules in effect orrthis date and that a copy of this record has been provided to the well owner. Well Contractor: Certification#: 00601 ` Date. --"'F-. z Record of Pump Installation Pump Installation Company:._ f\ ,L - � �� 1--��- Completion Date. Le >D t Pump Depth: I S-D ft. Static Water bevel: �j 1 1 ;f/t. Pump Brand: 1 5 -;j'I oSa Pump Size and Rating: f ll l�1 hp ® gpm I hereby certify that this pump was installed and wellhead completed according to the�Guilford County Well Rules in effect on this-Ate aqA that a cop of this record has been provided to the well owner. n/ / P 1 ^2 Well Contractor: �U / Certification#: PP, Date: RevIsecP January 1,2009 i