GW1--06652_Well Construction - GW1_20231017

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. :WELL CONSTRUCTION RECORD(GW-1 " � ' I Print Form
.• � For Internal Use Only:..
I.Well Contractor Information: • • • • • .
David.Belcher •
14.4ATIII ZONES • t
' : - VeilContiactorName. - .,. FROM •-"TO' • . DESCRIPTION . .. .
�lgl 3`r,. M•( c�tdusee
NC an.ContractorCettiQcatioaNam60r • k. :
Aq a Drill;Inc. : : IL.
CABINS(for mattt sed'Was')OR LII�ER pfaD( • 61e)
FROM TO • .DIAMETER _THICKNESS' ' 1 MATERIAL.
tamp:, Name. ' - • '�a fr. .-•45 ft' -G:•85'.1 , SeD M%' .--fit .
• 1 16.MINER CASING OR TUBING(atbthermiTelwed-16op):_
2.W ConitrudioDperlplt#: 4 txa•L Al 'FROM . - .TO -' DIABICIER.. -.THICKNESS NIATERL►L
aTPlicahle well ea sedan peradta(1.aiNIC,Cmm ,State,Variance,etc.) • ' . 1t•' fL: : ' :II-
3..W Ririe(checkwelluse): .- .n. •
. . . .�. .
•
W.ate•Supply Well: _.: • . •• . . . . 17.SCREEN • : . . . :
A' Cultural • - .FROM. . .To. . .' %DIAMETER.. SLOT SIZE • TDICKNESS . MATERIAL .. '.: .
Ge,theimal(Heating(Cooling Supply)• Residential Water Supply(single).. .It.. . • ..ft.. - ice. lnd .'aUCommercial'..- l
ResidentialWater3 '
•Itri:atioa : ' - :
FROM TO ' ' MATERIAL - EMPLACEMENT METHOD d:AMOUNT'Non4 •ater:SapplY.WeU:.• • •. . • •• . e ''' 401.10 •:6PHilt Mo ltoring• _ Rec • n &td r l Tl4.0 I4... ..
Inje ,on Well• . . Y B; .'. tL.
•
. ' „ : .: Aq for Recharge 1 . . • . i • .• : : -• • R. : °tr:: . • . .
• . . �GhoandwaterRamediatian. . .: . : . . •: i. : . —: .
_ .4 'for Stora8e and Recovery. •�Salu ity Hauler: - .- -. ' 19 SAND/GRAVEL PACKQfa110110 1e.)' • _ • • •. • - • .
A or Test S - TO CEMENTME HOD
toimarater Dlautage
.' Exp 'mental Technology. ' . : . •,OSubsidenee.Control:' '. - ,ft:. : .tb MA . •
. EM[LA .
•
- = ermal(Closed Loop) . . .DTracer. . " I
IL.P ', •. 2D.'DRILLING IAG(attach-additions— .
sheets ilneeeeeary)' .
i cnnal(Hatiag%CoolingReturn). 11Othei,:(oglsinundei#21 Remarks)• FROM:- •TO .' 'DEsCRlFFIox(eotor,r+araaa..eou►mesbanmaaln&e,eta.)
. . • O: .D" . db w
•:ilia ..
4:Da .Well(e)Completed:'q•e.6. 3 WeliID# • tt.' tt; .
W Sa.. II Location: • • .y0-R.' .:y5• .it:. . • /_ . .
rhdPcS . . . . . . . . . . . 45• 5)ti . -''I)h,te. &Felf toe •. .
Facility OavnerName Faclh m#;(ifeppltcable) IL" R, • .:
ar)'-IO c\(1, lrl• S4.pYlesi• tiei tie a73 tp-- - • ' . '� - • • , -. • r:.r.
. ' Physics Addicts;City',and Ziri . g,: • .
CU.);4'riik`) . .• • . . - . L-•o.�—..I ' '
• -21 t3EMARK6
C, _ , t7• GT 1:i Z�. . .Parcel ldeatiticadatNo(Pik]) .: '
Sb.La'tude and longitude in dtegneestodoutes/secoada or decimal degrees.: ' '.' - •. I.t~,` ;r-=. rm '::::c F 3 ,r
-:(ifweu Old,one 1st/tong)ssufaelato): . ' : ' • - : : •
8G6.141 u • • 22.Certificatloni . a�7
3A e� - N SO° I' 5t 5°'• • •N,'.' : ' -
6:I: • '- "tilewell a ..<��• . !9..47 3 -
. ) O rmanent. or DITemporary• .- • .. Sigrturo ofcer;ified Well Contmctor • . Date -
7.Is eh s a repair to in an:stiog well Yea or: No with h 1 CA• algnfna 0 C.0100 or LIANCAC 2C.tluit.the.0200 Well Coiiarotr)uetlon Standards and that '
Ijthi&lr �.ropolr,ill Out WelIconstructioa lyomiation and explaGt the naliaoial'the . 'oopyofthl&reead has been provided to thsarell owner:. .'repairs der N2Irtma•Av&unionoranthebatik-gfthkreao. • '. • . . . :' •. . . • .. : ' . . .
. - • 23.SIte:diagram or additionalwvell details:.
:8.For:.1,-.probe/DPT•or.eloied•Loop Gentltat�ai W.eW having ilia-sine .': ••Yea'may use the'baek of this page to prO ilde additional well site'detail or well:oonstiu tion,only 1GA!-1 is needed..Indioate TOTAL:NUMBER ofwells. sons taidlen details•You rosy also attach additional pages if accessary, . • .
_drilled:' .• .. - . . .. ...
.- • :••SVBMITJALl.INSTR[ICfIONS:
9 Tots well depth below laud surface:. 5'C)5 . . ' ' , .
. . Form ,le tvellelist all depthsijdj event(example-3Q2d0'and2Q1001 -' ( ) 24a:,etionto the f: •Submit ties form•within 3• :days•:of completion of;w•ell.'
• . . � � ' conshufloto firs followin ' • .
. 10.•Sta c water level below top of casings ' . '.50 • • - (!L) 'Dtvlsldn of Witer•Reso . . . . .
Ifwater ls'abnve casing,use+a urces,Information Processing Untt,
1617 Mull Service Center,Raleigh,NC 27649-1617
Il.for hole diameters • Ce' gip,). . � I '
�• n/� � � 24b:J oe Inleetton Well1i: In addition to sending•the form to:the address in 24a.
12.lye)constrnetion method: 1 YNlt` 'S •• above,•also submit one copy of this form within 30 days of Completion of well•.
• conslruction tothe foll
(i.e.Rol ,rotary,cable,direct pushy etc.) . • .-- owing • ,
FOR.' TER SUPPLY WELLS ONL-• vision of Water Res Underground Injection Control Progra .
• " IDl •�. .
. . .-1:630 Moll:Service.Center,RaleIgti,NC 27699-1636: • • .
. 13a._YI"d(gpm) ': A ' •' • - Method of lest:C Ct'1$T me' - ' •24c:•Ior Witter Snntiv Vic•Intention Weill-In addition to sending the form°to.•.- - •
o • • ' the.address(ea) above;•aiso subnit•One'copyof this ibuit-wlthin•-30 days of-
' 33b.DI , ecttontype:'NTh TO!b -Amount: i[ntz• .: completid.trof well consuuctioa:m the'colmty.heslth department of the coup . ' : •' .
. . . wliete colistivated..
Fenn` 1 • North Carolina l)eparhnant of Srtvhronmentel Qudity,Divlston of VUetcr ltbsources
• . 2222ot6 •
. . .. . . �.'RoVised c . .

GUILFORD COUNTY DEPAR ..
TMENT OF PUBLIC-HEALTH _
Division of Brivironmental Health,Water.Quality Unit
• 400.W.Market.St:,State 300, Greensboro,NC 27401.
Record of Construction; Repair,:or Abandonment:of a Well
Address of Well: 4nan:4)ecM 911r p 'lc, Skolke5d,IP,MC. ?23.5 LATITUDE:3 LI
WelLPermit Number- a3•oYalailla�t:.
,_l1c).QGk LONGITUDE , .s[O'
• Well Contractor Company Are to cjl xnr
Completion Date:346.
Total Well Depth: isA ft. Well Yield: 3 gpm Static Water Level: 50 ft,
Outer Casing: - Material:. . RUC = . .
Casing Diameter: fo.a Formations Log. -
5 in. Casing 45 ft. Depth :Description
Luier CasingFrom,Qft.To: Pei ft.
Material From o24 ft. To: uO ft. .
Cas.ng Diameter in. CasingDepth: . � .
.. . ep ft. ..From: in. ft._To if ft. rA1 ie Ctc•.'If+
. From: ,Grout
in: 45- ft.-To: .5��� �ltap C•ccan�e
Frm.__fiT
Depth. Material Method -From _ ft.To: ft.
prom O- .ft.To: air& ;ft: CFtient- .. +
ib- From. fG-To: � ,�, . �t�'°m'---�:To;,::ft;
From:
From:•_ ---- m I To:-. ft, : • - .-
ft.To: ft. From: ft.To: ft.
Water.Production Zones. ,..
Depth: AO.ft,• ft. ft: ft. ft:
-
Yield:. .,.:3: gpin� - - gpm. ., " -----ft:. .
gpm gpm- gpm gpm gpm
Method of Repair
Method of Abandonment:
I he by certify that this well was.constricted,repaired,or
abandoned according to the Guilford County Well
Rules in effect onrthis date and that a copy of this record-has been provided to the well owner.
Well ontractor:.. t . . Certification#: 459.4 -A D
... . . . ate: �. • �
Record of.Pump Installation
. .Pump Installation Company: , . .
Completion Date: .
Pump.Depth 4100 ft. Static.Water Level: C.0 ft:
Pump rand: L/1;LG,[i ere-os S+`�-. L'o .4L0 Pump Size and Rating:
hp gpm
I here y certify that this;pump was installed and.wel11head completed according to the Guilford County Well
Rules n effect on this date and that.a copy of this record-has been provided to the well owner.
Well ontractor: e,"7r G a? u .GL Certification:#: :1''7Z..G Date: d
Revised: anuary 1,2009