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Home My WebLink AboutGW1-2022-07702_Well Construction - GW1_20220811 Rrl lit " WELL CONSTRUCTION RECORD(GW-1) For internal Use Only: 1.Weil Contractor Information: +ktrdy ��1 X l `/ 14.WATER ZONES f Well Contractor Na mC FROM TO DESCRIPTION y. 'N - z IL /11 ft. G • ft. ft. NC Well Contractor Certification Number 15.OUTER CASING for multicased wells OR LINER rf a licable Aqua Drill, Inc. FROM DIAMETER TstcicxEss MATERIAL Company Name fL 19 ft. r'/q m, !/p s�t-�,,t 7 16.INNER CASING OR TUBING eotherrad closed-loo i 2.Well Construction Permit#.,-/ /9 'Q� k-C/ b is �J FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits rz.a.UIC,County,State,Variance,etc.) ft. ft. in. 3.Well Use(check well use): ft. ft. in. Water Supply Well: 17.SCREEN FROM TO DIAMETER SLOT SIZE THICKNFSS MATERIAL Agricultural []Municipal/Public ft• ft, in. Geothermal(Heating/Cooling Supply) -Prtesidential Water Supply(single) ft. fL in Industrial(Commercial Residential Water Supply(shared) 18.GROUT i hri ation FROM I TO MATERIAL, EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: ft• ft• CMPN L Monitoring Recovery ft. fL Injection Well: Aquifer Recharge [Groundwater Remediation 19.SAND/GRAVEL PACK if applicable) Aquifer Storage and Recovery [Salinity Bar17eI FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test [Stormwater Drainage ft. fL Experimental Technology [Subsidence Control fL % Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary) Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardaess,soiltruck type,grain sir etc. O It. 40 4.Date Well(s)Completed:' Well ID# _ It. �V Sa.Well Location: ft 15 57` --i-z t Q ft. ft. Facility/Owner Name Facility iD#(ifapplicable) ft. ft. (,(-I oq 1z nc C:,a S 54rz� Pkils" GAj� ft' ft Physical Address,City,Sod Zip fL ft. S I 1 F6)t 21.REMARKS y County Parcel Identification No.(PIN) r 5b.Latitude and longitude in degrees/minutesfseconds or decimal degrees: MOO Irlficrl�.ia:+'� (ifwetl field,one lat/long is sufficient) 2L Certift lion, N W - -2 z- 6.Is(are)the well(s)&Permanent or OTemporary Signature of Certified Well Contractor Date By signing this form,I hereby certify that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: 1[Yes or oNo with 15A NCAC 01C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a Ifthis is a repair,fill ora/crown well construction information and explain due nature of the copy of this record has been provided to the well owner. repair under#21 remarks section or on the back ofthis 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. drilled. SUBMITTAL INSTRUCTIONS a- 9.Total well depth below land surface: 1 S, (ft) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths lit different(example-3Qa 200'and 2@100) construction to the following: 10.Static water level below top of casing: '30 (fL) Division of Water Resources,Information Processing Unit, b'water level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter- (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a 12.Well construction method: 1A r f7 iz above,also submit one copy of this form within 30 days of completion of well (i.e.auger,rotary,cable,direct push,etc.) construction to the following: Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) ® Method of test- 1 24c.For Water Supply&Iniecfon 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. d completion of well construction to the county health department of the county where constructed. i Fort GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 i 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: G'JOR 1�OTc�t Pp� ��ryr k j�Ae �yTUDE 3 Well Permit Number: �� ' 1 d '�1't� {�Z ' Q�� j LONGITUDE Well Contractor Company:AQ U 14 - Completion Date: ') l22 Z Total Well Depth: I ft. Well Yield: 7c) gpm Static Water Level:_ �� ft. Outer Casing Material: iZ - 6C Formation Log Casing Diameter:6�c�in. Casing Depth: Depth Description From: 0 ft. To:_!K'_ft e� Inner Casing Material: From:'Z4 ft. To:C O_ft.. �b ►vsZ �oGj��- r►�vc3 Casing Diameter: in. Casing Depth: ft. From.'9_ft. To:jk!�:7ft. j2 From: ft. To: ft. Grout From: ft. To: ft. Depth Material Me hod From: ft. From:i� ft.To:, eft. Cep - v From: ft. To: ft. From: ft. To: ft. From: ft. To: ft. From; ft.To: ft. From: ft. To: ft. Water Production Zones Depth: );W ft. ft. ft. ft. ft. ft. ft. Yield: �1 U 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. a Well Contractor. Certification#: 4 V Date: <�/ - a2 Record of Pump Installation Pump Installation Company:_ �,� kr_ I Completion Date: a Pump Depth: TYO ft. Static Water Level: Pump Brand: VXN_Ae r-S �S�S - I aPL(-cS- Pump Size and Rating': �c� hp L D 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. Well Contractor: .cam ?� e � 1 ��' _ Certification#: Date: Revised:January 1,2009 i