GW1--07396_Well Construction - GW1_20231117

.. • :. '.. . . ".. . . ... . .. : . Pr�rlt Form •..
WELL I CONSTRUCTION RECORD-(GW-1). • For Internal use only: :•. . . , •... ..,`
1.Well Contractor Int'ormmtion; : : .: • : . •. . • : •- . : • . :• : : : •. • : .: .I . • . • ; . ;
David Belcher
EH
' Wall Connector Nama - . - PROM . 10' DF�RWOiii • • •
4594 A - - 4ao' L3 l; "50•C-(VIt'f c rp.1 • :
NC Wei1CoetiecturCatitiodonNo Atr. ".. R. •. .'
: 1S.0 O( cl ds a NO-
• " � UTERCABtN m NiaR'dB ORLIIVER(if A ) " •Aqui Drill,Inc; .. . .. . • •PROM•• _TO. •- DIAaonOa _Tsncravr�ss-• . novozo L . •
pa Name • :q4
I
•
2,W Construction Permitii •p�n2-1 /,JNI4P-Cbl l$ ' • • PRo • - -;MAIRHUL
u.nviveRc,�lGo iteo
M• TO'� D:ANm'r'ER;
:Ihtdl bpplLazble wa116atsarrctlonpesmlti(0::I W,:cb mp S"KO/meetere%) it ht. •
3.'WUse(cteckwell.nse)... [t rw, i.. ._
Water'
- • t tmrei... - • • ' : : '� �i�. .."a -T7R S$ MA R1AL'
uiilio
. raoMl ' TQ - DUNRirEa "SLo'rR�R t
.ft. (t. tm•
G " .. �- -.Cook SuPPIY)••'I aiResidenHel Water Supply( e) -
. lndut'hial/Cornmercial • .
enHal Rater Supply(shared)
hriAatiaa. � - _. -
1@PRDM. MATRerAL
" -: `Non:WaterSDPPb'Vt!ell: " . . - ,• ., IVT' aentotmlt'
Mcai'torldg ._ . :.. . . : •"• '.• . . • 1.4 •:•;93 f.t! •('patell•iL::: .'��r•�4i,;•I'h u. '.. •. . .
" �aroundcvaterHemedititimt. ,. .
'• • • . -Storage end Recovery•." CISalin tyr Hetzler :: - ..TO- psi anatomic.1e) ; _ zesrl.ACEatrN1'!screen :.
ACl Teat- - : . • - . •E38tetmdcatarl)r®incge . .
-+ , 1.tal Technology: • ::0Subsidenae Control 0. S:
::. Creethoraie'I(Closed Lo . . ......•"� . .. .•'.. . , _ •. ;•: � ::. ".
op) - ".OT er • • • :20.DRILLING LOG(attach add[tloaelthesaIfitasire) .•. • S.
(Sea$nR/Coolion$ecam) nO&er(egplalaDndtx#21Reinadrs)
PROM TO . ' . Dnaca1P'rtoN(sopri,t}.an.u..nll".aNcamRad .tc)• 1.
two
.0: a® .fir .Satr��• Sfa,l:
4a ate "elt(e)Comp! tit• �.i•t r Weil D)1) iL tr: � •• . 16• .U1,4 1t10 ;& 4P
Sa.WeIILoeetlonc 1,14 ft* qtltj' It
" . • Fa lyi - Name . . .
PaaUIryID#(iPapp1Uu61e) � � !
" . . - .• e, -idt, _ 6i: C-cct'.l�.OS het riot j tic. �1K5 : : - _ <z : : " : - �--� '1
• ::oft. •. • y Ti 5
•
till.titri4 - 21 REMARSB' _ i''- 2�
: )
PatoclydabtiflcatinnNo.(PIN). NUv a .: `L. :.
wdkada Ind fl i�•o ta>longitude In degr'eeelmipgtedseeoads or decimal degrees: .. •• • - ' � ' :•� -''•a' ' '
514fid ot) '22.Certi ication: • • •• ' tf'`" ` �1•i' `' •
hi' i. O" N . 779° 491' t5:O'' W n
I oti�p lid- .3 "
6.40 rc)the well(a)Peerni inert or;Temporary: • .. 's goatara ofcenlaed _o eamector : : Date
18 N• • ` BY stifling this herebyoerty that the tiveU(�was(,yore)constu7ed i awondwoa ••
. 7Is tha roil*to in el tingtvelj; �Y®g. or 140... •• • • ivlth/Sd NCdCO2C.0100 or 1SAFetC 01C,;Oko treliContrinetlon istedardsand the e
trilitslecirpr ak fill out Iniemt wellconsttucllan.Geo atka ands O;theQaairr tlu .copyofthisrecdnd kit beep pm"uldedto fhe well owes:
reparuil, N21 semailareaton Cron tb4aek. this 41 •
4f ! .' . . 23.Site dla •gram or ad',dltioDalwell details: -
8.For be/DPT or Closed:Loo Geotheruri Wells having the cane You may,use•the:back_of this P page to provide additional well site details or well
. oonstsuctton,only 1 OW.--1 is needed Indicate TOTALNUMBIIR of Wells -. ' ••• construction delaila: You may also attach additional pages ifacceseaxy
•. •J4UBMW5'AL INSTRUCFIOPTS
9 Tbtal wew depth below 1afd surface: '• e. •2oo a w .'" . • • (fit.). 24a.For Ali Wallet. Submit this foam,wit•hin.30 days of completion of well .
Fom�ltlfpiewelbiMagdept14U li ereat.(ex Pte•4@•200'oud2®I00) ' •
- -. 10.Static waterlevel below lopof asingt • ,�,t? - - " . . , vision o Water :
cnet:nctiaa _
umterlcvel(aabovacasi.i0vse +.. . . s;kkil tglhEC eocese1617s•t;
(B-) DI
1L Borehole disputer: . (p• - 1617 Mall Service or,Raleigh,NC 27699-1 7
r
I%Well consttruetioa iet6odr .. 'd5E94•ict • • / c . .. . " above, l oleouon io copy cop addition
to Within•3ntutig o days orm f o>thnpl oaaress f w ••
(La baler rotauy.sable;dtrect'pnsh,ete) • - construction to th• e followinn:
FOR WATER SUPPLY WELLS ONLY: Di•vision of WsiterResonircea,IIindergrougd Injection Control:Proiram, .: '
• ` 1636 Mall Service Gamble,Reklg6,NC276994636
13v:Ylejd.(gpm)• . . ' •.Method'off C•}&) j-Tty,cr 24c.For'Water inutile&fnlectionIWei: In addition to sending the•lbrm to :
13b.Disinfect_.. - .e: 1.17►-J,J(:•__,• .. • Ant :. a i ve,also . : o copy of this tbtm within 30 ditys,-of
.l�o©Z completion of.well to tba County he*address{es) bo submit rot
department of the county.
•
�P • -
" here coastrticted:
. . .. w
• yam ji NorthdereiinaDepaitm®atofBnvlronmental Quality-Divisionof Witter Resources
Rovised2-22-2016

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH .
Division,of Bnvironmerital Health,Water Quality Unit
-
40 U W.:Market St.;Stzite 300,.-Greensboro,NC 27401
Record of Construction, Repair, or. Abandonment of a Well :.- :
Address,Of Well ` `O9lun1ecsc .1
s, (keeen5hen-O,:.NC /)7?155. LATi1'uDE 3fj_ lei_ la .: o
ell PermitNumbcr: ova- la -I_mH9 'ni�tt3
Well •
Contractor Co an- � - - --
� � ' ONGtT-
mp y: I a 'Drill In �:
.. . . . � c � . . :�Completion Date:. .!1 Li.=a1 .-Total Well Depot 4y j. ft. •. Well Yield- 56._:gpm Static Water Level 3 _fL
. Outer Casing Material /Pit
C m Diameter:. F orma�on Log - -
g (0:9' 'in Casing Depth' 4y ft.: -
.. .. .Depth- ' � � Description. -
��,,�r Coe : •: P m To 1 '
rasing. Material
- - -From: !r"i it TO: UU1, ft. �lil -. , ,. ;¢e
asrng:Disineter: :`'in . . -Casing Depth:` . � ft.
- �F ft To:
From: .F ft..To ': ft. .
Grout
From, ft TO::-
p -:; . . . .Material :;: Method :: From -it:To.
ft.
:_G ft:To:4!1 :ft. Carnet 4 i
rom �ft:To
-From: •It.To: ft. . From ' .. ft. To:
: � : From. ft.To:. ft. . . .��� • � L.
Water Production Zones . : . .
bepthc. Uao. ft. ' .f}:.: I :
:Yield: :gpm . . -----ft. .. - . - -77 ,,.f . ft:
� - ft.
• gp .
. .. . .. . ... gl� . -gpm gpm
gl� .gpm .
Method of Repair ._ . . : . . : .1
Meth d of Abandonment.: • i. .
I here y certify that this well:was constiucted,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: (aid` e, itr&; � .
Certification#: 459E1 4. Date: II-�: .
Record of Pump.Installation. I
PumpInstallation Company: - � .D���l\: I . -(.,1C: r•
� - - Completion Date: .. !,./ g'.�'
Pum Depth: ft.
P ep.. . Static Water Level:-=. �'�,, ft,
Pump rand:.-C6•-?� ,'T'.1m'1a-6?1 C)$C 7 Pum 13 j
. .. . p Size and Rating,;.. . y . hp j D gpm
I here certi .,y-certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules n effect on this date and that:a copy of this record has been provided to the well owner. i
/ii/0? ?
Well Contractor: 7,.+P t eb$e - - Certification#::o�1:QT1` te.• f
I •
Revised:Fetusyi,200s
I