GW1--00936_Well Construction - GW1_20240209

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For . L . :,
WELL CONSTRUCTION RECORD.(GW.1). • .. • "
. Internal Use Only:
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•,1-.Well contractor Information:.
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Chris King . ' • . 14.WATER ZONES - - • ' . , ' E. '.. - ' ,
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Wcil CoStraCtOr Nama . FROM. .•TO: . ,' •DESCRIPTION '. . - - .. • 1. . .. ..,
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2080,A • • . - .200. '• Z IL' jot a ,. ri
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NC Well Contractor Certification Number•
• • IS OUTER OUTER,CASING(for mold-cued wells)OR LINER Map liable) - .. •:.
_Aqi.12'Drill;Inc.. • FROM'. . TO' ..DIAMETER. .THICKNESS. ' .MATERIAL. ....--a ft!: ltd. ..ft...: GPk. ii.': PtEtC : -Ad.' . . • . -. .
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CompanyName.• '
i ..,... . . . ,,, I6.INNER CASING OR TUBING(geothermal cloud-loop) . -
. . •DIAMETER, • . !moons• • MATEIUAL . . . ,• , .-.
2:Well Construction Permit#:/c/: O
b. 46,1,14,01&_-03q5.7-25-FROM . . . TO•
List all.applicable weil.construction permits(i.e.UIC.County,Simi. aritince.etc.) ' -_ ft, • ft ' 1,11', , . • . ._
, - 3.Well Use(cheek well use); •. . :ft. : :ft.. : • • tn..
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.. '. .Water.Su Well:.' . ..
. . • .176 SCREEN -.. " . ". ' . .
pply . .
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• .PROM'• ' .TO• -• . DIAMETER SLOT SIPS ' 'THICKNESS MATERIAL'' .E1Agricultural ' ' . . EiMunicipaYPtiblic. ' • '.1e. • . rt.: ' In.•
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. •uGeotnermal(Heating/Cooling Supply) ..eResidential Water Supply(single) •• • • ft.;, . oft '. . . .In.• . • • • • ••. .Olndustiialtonunettial. -13iiesidential Water Supply(shared)'. .
.GROUT
• .1Irrigation -- • • • - " . , . . . . FROM- •T .. ..' „MATERIAL. . .EMPLACEMENT SIETHOD&AMOUNT.. .. •
• : Non-Water Supply Well . . . .ity 'ft: ./ •ft..
w• - e-P-1111/4'.. 7/Eti c(C. . . . ••
• ,01Monitpring . .. -ORecovery' . . . - . • ' ft... . .• ft:. • Injection Melt:. •
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rt.: .• ft: • . .
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. .. AqUiferRediatite • :E3Groundwater Rcmcdiation. . .' • , . . • . . " . . .. . , , ,
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.19.SAND/GRAVEL PACK(11 applicable)' - • . .ElAquifer Storage and Recovery . 0 Salinity Denier' , FROM . TO . - .. • MATERIAL. . . . .. . .
. .EMPLACEMENT METHOD' . • •
DAqUifer Test- . . '.•DStorrnwater Drainage . •
• Experimental Technology:- DSubsidence Controlft: :ft: I• '
Geothermal(Closed . DTracer. .-. : : . . . : : : . . • . : .• . • - • '.. • .
• 20.DRILLING LOG(altach additional sheets If necessary) . •
FROM ' • . .I , ,- • ,
nGeothermal:(Heating/Cooling•Return) .nOther(explain under#21 Remarks) TO
TO CIESCRIPTION(color tardnets.nil/rock type grain size ete.)
. . i ,-2.__•• .0.. 1.4.::3.. II": g.041,. C IA y. • .
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41.1Date Well(s)coinPleted:, "ir26 -_ _ ,' Well ID#1.:41)1-.-1. .:-.). • .3 ft. 73-7•ft.,: ykid'. .g
1 61° • . , .
5a.Well Location: . '7S7"- ,2sSt.,.- ible • dii Jqlotie . . . . •••• ..
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Facility/Owner Name• Facility ID#(if apphicablc) ft
• I. r.•.,f"'"'.f`'''',-r-11
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"4-'. .. -C*6‘PhotLo- ov.ie . ..,
.Physical'Addiess,Cilyjanci,Zip • 1-1- i) 7024
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. . . : .21.REMARKS • - . .
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• . Minty. . • •Parcel Identificition NO.(PIN) .i.17-7'. - - V .• ...,..;;.:`, i..1c.1.7.:ezi owri.n Poio.et'su..CAMIge.5 Uhl', , ..
.Sb.Latitude and longitude ln'degrees/niluutes/secondstr decimal degrees:. % .-. : - - ' :- ' .' • ' • •
(if well field,one lei/lengls:sufficient).
:22.Certifica n:'• . .
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6;Is(are).the w.ell(seMPermanent ..Or.:E)Temporary. .. Signature of Ceti:icd Well Contract - - tr1 ate
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.DYes- • •ax"signingthis form;/her*certify that the well(s).was.(were),constructedbi.aceordanec•
:7:Is this a•repoir to an existing . ':well:: : :Or.Mo: • :with.ISA NCAC 02C..0100 or ISA NCAC 02C.0200.Well Constntction Standards and that a
If this is'a repair,fill out knoint well conuruCtIon Infonnation end explain the nature of the copy.oft/its.reconlhaskeen provided to the wellowner..
-repair tinder#2 I remarks section or on the back of this form.- ,
• •23.Site diagram or additional well details: . . . . •
S.For aeoProbe/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
.constrection,.Only 1 GW-1.is.needed.Andicate TOTAL NUMBER of wells'. ..constructien details.You may also attach additional pages if necessary.
dtilled:' . . • , -
- -SUBMITTAL INSTRUCTIONS . '
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...Tottill well.depth belOwland surface: • ',2 .1? . • . •
. ' . 0-0. 24a. For'All Wells: ,SUbmit this form within 30 days.of.completion.of well •
For multiple wells.list allie'entits Ildrerept leinmfile7;1®20Wand 2©1001 ' . . construction to the following.
•10.:Statie water level lbelaw ligrof casing:' - 60. •(fi.). Illsilslon of Water•Resourcesilnforniation.PrOcessing.thilt,.
fwarei!miens above cining.tree"4-"'
.1617 Mall Service.Center,IltaleighiNC.276994617•
11.11orehole diameter:'- ' Co. . •(In.) ' • - .
24b.FOr Inieetion:Wells: In•addition-to-sending the.form to the address in•24a
• above.-also submit one coy'of this.frm o within 30 days-of completion•of well'
12:Well construction Method: A 1!?.' .p. li ' • - construction to the following: • - i
:(i.e.auger,rotary,•cable,direct push,etc.)" -
• • " ' ' • •DiviSion of Water Resources;Underground Injection. ontrtil Program,
FOR WATER SUPPLY WELLS ONLY:.. .1636 Mail Service Center,Raleigh,NC 27699-1636.
13a..Yield:(gpm). .3.6. . .
. •Method'Of test: .----9.,,
- <., . 1,4- - • • i. . . .
. 24c.for Water Snooty&•InlectiOn Wells: .in addition to sending the'form to ..
.,_)*to' 'A the:address(es) above; also:Submit.One'copy of this form within within'30.days of
.• 13b.Disinfection ty;iei. f-t: f- :1-r. .Amount /4.O.T..-. -. .completion of well construction to th4:county health:department of the..county
.. • - •where constructed.
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• Form OW-I . Minh Carolina bcpaninent of Environmental Quality--Division of WaterResoUrces• .Revised 242-2016
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• -GUILFORD COUNTY DEPARTMENT OF:PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400W.Market St;Suite 300,•Greensboro,NC 27401
-.Rocord of Construction,.Repair, Or Abandonment of a Well
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Address of Well:419Y' e... ree? cork). Pi. 61-erw570/Z 0. - LATITUDi.3 : .
Well.Perniit Number:4 0 .--/-jrt)it M -C)3Cf.5-':g. : :LON0111:1Di . . :
:Well Contractor Company:. .Aoua'Drill, Inc. : Completion Date j•-',..Z A:V
Total Well Depth:2 (657- ft: : Well Yield: 3 6: ,gpm, : Static Water Level: CO ft.
.Outer Casing , /Material:5Pa-21 et eh d- : Formation Log
tog
Casing Diatheter:,Go,Material
,:in: Casing Depth: 10 ft. Depth , .. DesCriptiOn
.FrtuniLft,To__3 ft. r el: .ehq
Inner Casing : Material: From ft.'.11.O.257-.ft; 5'AS d jatic.IC;
: Casing Diameter: in. 'Casing Depth: • 'ft: .FrOM:75.7ft. TOar), :ft. /Skit 60-Piriti4r
. From: .ft. TO:' . ft. •.
Grout :From: ft.:To: : ft.
Depth .Material : ethod : : From:: :ft.To: : : .ft„
From:C) ft.:To:RV) : ft. eivoi&Al.,- /RUCK From_ ft.To: ft. ..
From: - ft,To; • ft.. . : • .* • From:: . :ft.:TO: ft.- •
From: . : ft.TO: "ft, ' Prom.___ft To: . ft. • .
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Water Production Zones: 1
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Depth: ;26.0ft. ft:: ft: ft. * : 1 ft.' 1 1 ft ft. ..
Yield: .36 gpm- -___gpm : : gpm : :gptii: ._. .:gPin ___gpm ___gpm
Method Method of Repair: . : i :- : !'
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Method of Abandonment: . . . . . . . i
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. . Ihereby certify that this Well was constructed;repaired;or abandoned according to the Guilford County
' .Rules:in.effect on.this date and that a copy of this record has•been provided to the well owner.
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WeItContractor:‘11`"0 'ZN,...0 • " certification A 20804" Dateii"7,247—.2 9
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Record of Pump Installation • , . . -:
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Pump Installation Company • icly.A : Z-V.I:i 1 . 7.-.r C.L. • •cOnvietiiini Date:J i.ai)_• •
Pump Depth _15i2.L..:ft.. Static Water Level: i 4D ft:
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PulBrand.: At7t.:(0\5e TQcr--yi. --E'ic:%*) pu
.'71irip Size and Rating: %3 J . :hp i D. gpm
ine by certify that this pump was installed and Wellhead completed according to the IGnilfOrd County Well
Rules in in effect on th' te and/hat a copy of this record has been provided to the well Owner.
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Well Con 2--tractor: : 171 _, - CertificatiOn 41.:( aic:42 Pi .Date:
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• ,Revised:dap9ary I.,2009
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