GW1-2022-06895_Well Construction - GW1_20220718

f
WELL CONSTRUCTION RECORD (GW-1) For Internal-Use Only:
1.Well Contractor Information:
Spencer Adams 14:WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 295 ft- 325 ft. M
ft ft I1
NC Well Contractor Certification Number
`15.'OUTERCASING:firmultl4asedw01s'ORLINER da 'licoble)'.:
Rowan Well Drilling FRObt ITO I DIAMETER THICKNESS brATERIAL
Company Name 0 ft. yg ft 6�14 in. SDR21 PVC
22—�3—�N� �R—��77� 16ANNER CASING OR-Tt7BING. eothermafdosed-loo
2.Well Construction Permit 1#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(r.e.WC.County,State,Variance,etc-) ft. tt. in.
3.Well Use(check well use): ft ft ln.
Water Supply Well: =i17 SCREEN
FROM TO - DL1114ETER SLOT SIZE TffiCIGYESS atATERIAL
C Agricultural. Munici al/Public
p ft. ft I'in.
Geothermal(HeatinglCooling Supply) DResidential Water Supply(single) ft. ft. in.
IndustriaVCommercial OResidential Water Supply(shared)
18.GROUT.. `.t:: .:.:_
Im ation FROM TO MATERUL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 20 ft. 3 ft Q Seal Pump 6
Monitoring E3Recovery 3 ft. 0 ft. Holeplug Gravity
Injection Well:
ft,Aquifer Recharge Groundwater Remediation ft.
- `
i Aquifer Storage and Recovery QfSalinity Barrier 19..SAND/GRAVEL PACK if a licableFRoat To MATERIAL Ei1rPLACE11tEdTMETHOD
Aquifer Test O'Stormwater Drainage ft. ft.
Experimental Technology OStibsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20:DRILLING LOG-attach addiddiial shee&if n&i!i"1ryV
Geothermal Heating/Cooling Return) Other(explain under##21 Remarks) FROM TO DESCRII TION color,hardness,soilfroek e, in size.etc.
p ft 10 ft* Clay
4.Date Wells Completed:6/29/22 Well ID#01776 10 ft. 60 ft.
P sandyOverburden
5a.Well Location: m ft. gg ft- weathered rock
Mitch Powell us ft ga ft, sofidrock
Facility/Owner Name Facility ID# ifa applicable) 118 ft• r40 ft•
(� PP ) Brown Rock
614 Gray Wilson Rd, Colfax 27235 ft• ft. 02?
Physical Address,City,and Zip ft. ft.
Guilford :21.REMARKS::.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
36617.245 N 80055.884 W r
lz-L-
6.is(are)the well(s)lx Permanent or'oTemporary Signature If Certified Well Contractor Date
By signing this forin,,I hereby ceitify that the irell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or [qNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200{fell Construction Standards and that a
If this is a repair,fill out1knoun ivell construction information mid explain file nature of the copy of this record has been provided!to the well owner.
repair under§21 remarks section or on the back of ffiisfiorm. 1
23.Site diagram or additional well details:
8.For Geoprobe/DFT 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 tCi 200'and 2@I00) construction to the following.
10.Static water level below top of casing: (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: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of,this form within 30 days of completion of well
12.Well construction method: construction to the following:(i.e.auger,rotary,cable,direct push,etc.) 1.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Alai]Servicei Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: airlift 24c.For Water SuDDIv&Injection 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: chlorine Amount: 15 completion of well construction Itoi the county health department of the county
where clonstructed.
i 1
Form GW-1 North Carolina Department of Environmental Qualit�-Division of Water Resources Revised 2-22-2016
t

UILFORD COUNTY DEPARTMENT OF PUBLIC HEA LTH
G
Division of Ei vironmental Health,Water Quality Unit!
-400 W. Mzrket St., Suite 300, Greensboro,NC 2740�1
Record of Construction, Repair, or Abandonment of a Well
F
Address of Well:���� r "'jUi� 7�yt21 . LATITuoE 3C
2Z d L I �t)1�7� f
Well Permit Number: , T LONGITU®E � 4 �5 . FjP/
r.
Well Contractor Company: 00Uy M tL(' �� �`0/ 1.:� Completion Date: 6,12-al
Total Well Depth:_ft. Well Yield: gpm Static Water Level: _ft.
Outer Casing 1VI rial: 5 r 0 PVC.- Formation Log
Casing Diameter: in. Casing Depth: ft. Depth Description
From:_ 2_ft.To: d ft. — COV
Inner Casing Material: From: ft.To: ft. J aAI w bi_vde
Casing Diameter: in. Casing Depth: ft. From: ft. To: ft. L✓Eit �
From: ft To:_rLUft. 52� ' ✓'��LC
Grout From:�ft.To: 0 ft. {�z,�lv
Depth Material Method From: ft.To: ft.
From: ZO ft. To: 3 ft. FZ-5,mj PWIVLP From: ft. To: ft.
From: ft.To: 6 1. [*Lev if, r" ^4 From: ft.To: ft.
From: ft.To: ft. From: ft.To: ft.
Water Production Zones ,
Depth: ` ft. ft. ft. ft. ft. 1 ft. ft.
Yield: =6 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.
Well Contractor:�5Rai6e,4L,- Certification#: - Date: z Z�
Record of Pump Installation
Pump Installation Company: -b Loci-n W L'l Drill; Completion Date: 7 112 (Z 2-
Pump Depth: 200 ft. Static Water Level: /ft.
Pump Brand: NA41-rs Pump Size and Rating: 112 hp 1 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 a copy of this record has been provided to the well owner.
CWell Contractor: � Certification#: Date: � i 2- 2 2
L
Revised:January 1.2009 y
i