GW1--02759_Well Construction - GW1_20240506

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WELL CONSTRUCTION RECORD(GW 1l • • • Fo -Internal Use Only: • . - ' ( Point Form;
. ! Well Contractor litibi ntitlon.
Gary.Thompson •
.. .. 4•
Wall CoatractorNamc .
. . !1.WATERZONES - -
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441.8-A: . • .: . .. . .si.p�• ,54:3. Cr4c4o r
pp •"1-.(r PM
NC Wep Corrttaotoi Cadrfigatiori Number'.: p.',�
' : Aqua Drill,Inc.. atfor,mlD> Bnew)ORLINER[+f.n
FROM MAT1sRut .. .
. .CompanyNeos i�. ;"'.0 f4.I aS 'L: SO -
.1 INNER CASINGOR TUBING emethermai
_Lieu Cnadniction Perttiii#:2 •:1 o iN R -OO4 .% 'DL1ME11R p .
•LIMiiillappemble Ea CoMbuctlon peon/O(l e'•Egg Colagy, 7ra1e,Varlana,ref. •. ••R: .,ft- ' - I lo.•' . . - • .
•3,Weil Use(ebedcwell use):. • : • .. . • • tl; ..tt,. . . { . . :
Water SupplyWellt : .' :: : 17.'SCREEN ; '
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:. ' : Agnciiitumai . : •. ..
- FROhf .70 D R BIDTt+7Z6
. �MaticipailPnblia 1 � ii. ki; "MI.
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QeoUtermel(Heating(Cooling Supply) Resideetial•Water S ly{shtgte)'
T+Dcla+�ss MArlatuL-
. .• " IndustdayConmteiicial - .. •ta' .
Rasidantial WatecSupply(efiared) •. � 18.GROUT •- -
Non-Water 9u
-PPb!Well:•-`` . • •. . .•. . • •
'IRrJtL►L
Ce*►{ htPWtCdMBNr • AM.PROW TO' ._E 14tB77r0DA 11P1'r
h
• •• . . - •- ••
u fur Recharge. tt
�(imtindwata Rernediation •
Aquifer Storage end Recovery: •r)Sali iityBaeiei -
• 99:8AND/GRAVELtACK(ifeDWkk�hle) : . �'
Test_ • • r MATERIAL
Stour vietef �,�,int� i ..• .
FROM TO A
clltei �bno' .
.
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1�41Pr.ACEMFdrrhlElirOD
�Subsidrnce Control - ..- It.� • 14 . • •. ,
:• Geothermal(Closed Loup) : ' .le .
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• . "'t �(ospleinunder#21 Remarks): FRo :d -
. 0.DRiLLIIVGLOG[aHseh additions' -
• GOOtb0Ym0l(HQtleglCO01ll1RRetUm) .: Olhr:r. 1 hi 9D--.� � D➢8CRIFT10NImtar,Y�ad�ev,�IVnsYbu4�IFu,ety.•-
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. :•q ge: DST.k• 1 '-:f.-A6,l:. :
4.Date Weh{i)Completed;1'1'1�'a�i .WeBID# �' I:fil �S ft-'
. . Ia.-wilt Lin::: . • 6S- m 16 -' '(yr'GAa l
'.Piewc -Finale :.- korweg . • - • - 770! S S -
•• •FacIlriy/OanerNuoe : •. FaitlityTO(Ifappitcable) - . L. f.. - _ •
: . .:�.00c Scoc,1C .CZ,id - gale t,L W;1 a* r E'; _. . I,
. . . .RhyslcelAadiese,Cuy,andzlp . . • ,. .•
.• . • . . - 0 i L , --- '
6.-6"
.i"i:iror d:.. 21.REBIARKS - ..... -. •M.
Paioel Idooti5cadoa Nal(per. I r` :i • 7`)rr.1.: N ,ikk-: : .•
: Sb.Iiititzde and fongitads in degrees(minutetilseconds Or dechnal d
..„ Given Bad,ono 4610n0 is saffiakra), �' .
O y r i 22.:Certliicatioa
b:.S. . .. •lv : .(8U"'I .11 :.a'' :i. : W ;`
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6.Is(are)the well(e)pfPermiiient or DTemporary' .. . . : - • , signature off well Co .• ctor •.•'• • .. - • Li .: 4 -.•..
7.L gill*ti ee to an ezledog •,- ••- •• listgrti tiltsfoma t'.hnehitiertJy drat'the neliO)rat-(weroj cnnshuc�ed to aomridatee-
: :EYee• 4. ONo with7SANCAC 02C.0100 or 1SANC C,01C Oa00•Wel1 Coasavclton gmndiidr mid Drat o Olds Li arrpaalr,JlUoutiatosvi well conshrrctian igfinizoffon andorplala fheOcill.eofthc • •cWY.4r.hla rreoiid/waheepprovtdadl0 rheiddl oiprier-. :..
repairrotderf121 remanissecNonoronthobaekojthlrf• am
•• . ' • : . • • • '•23 Slt�ediagram Or additional well details - ••• • •
8.F GeoprobdDPT or Closed.Loop Ceathermsl Wells Laving the same . You may use the back'of this page 6o proylde.edd:doaal-well vita-de*eils or%Yell
on;only.'G.W 1 is needed Indicate TOTAL NUMBER:of wells •.•-construction details: You�4'also attach additional pages if neoessmy.: '
9.Totel well depth below lend surfacer .• •5.435- i S farm .
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p[IBMITTAL INSTRUCTION
For mrdiple l4g1 Ilatpll depths Ud m(eipte•3Q200!and7®1o07 ...I ( O days of completion of:well
24 .k'er AB WeAs Submit this wifltm 3
10.Stafc water level,below top of oaf 6.0 j ctroa tothe.8dtoavmg:
comstrd
rlt Sir level tl a�eve cos6'2 r:1;/OP '' • . «)- -Division or Water Reno informstioa Processing Unit, :
!' f . . •, ' 1617 Mall Service ter,Raleigh,NC 27699-1617.
11.Horebole diameters, t7
.. . D. e W n -
24b.�oY ini n• e s: to the address in 24a •
i cHe To addrtloa sending flte farm to
12.Well contraction method:'- R©'#t:otr. f y a +e,also submit.one copy of this form within 30
Oa.6ngaC,rotary,mbie,direct push,eta) •. • construction tothe followIo•; 4 {
Boys of•completion of well 1;
FOR WATER SUPPLY WELLS(NLY: i Division of Water Resources,Underground 1nJedton Control Program
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-13a.Yield,(gpm) �' "1 1r�'�� - . 1636 MillBeryIee Center,Raleigh,NC27699- h .
Method of test:• t,e�1dI d.r% 24c.j+or Water t3Hunls&_Itllectlonl Weld: In addition to lsend'mg thefaam to
•.' : • Q' - the.address es•abo also submit:bie'c of this form Within 30 days•of•. 130.Dlslifeettoa 14 T,1....in•l� t O +�o• 'Copy. .
type: Araetlnh DI�. completion of well construction to the'ounry hea1W.department:of the county
where conshuctrd.
Penn OW=1 ••
North Ceiollna tlepaitmest ofRovimnmegtul Quality-Division of Wetcr Rtsources I Bribed 2 22.2016

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Gt1ILFOIIb CO y`DEPARTMENT OF—PUBLIC HEALTH- .
Division of Enironinenj Health,Water Quality Unit :
400 W.Market;St:,Suite 300, Greensboro,.NC-27401 .
Reesrd of COnaitii t t©® © [ ep ity Cr ilOpil di®8ni9ti..
Address of Well: aOO I :Dock R cI e • : : S �k act t 1713
• °. Well Permit Number � LATITUDE"� • .
• -- - � LONGTIME :•-ate"• -- :����,.
• . :1Nell Contractor Com an -: . . � • .. . '""—`
. Total Well :: :
=�- • Date: 4
Depth: , •..ft. Well Yield:-
..i - : ' .. . _gpm Static Water Lev
ft.
g Material
..;Casing Diame : . . . �3Fon�a - .: •
Ill:.in: .
ter: ��• I• �®®� : . .
• casing • • -.�ft. . . � • : . g°: .•"
" . . Depth -" Description
Fronir" O P
: er Cash Material: 0::I t To C : t. :mod. [hoc 1:..44
CasingDiameter: From: :a1 i
To� , .
: in:.:"�m D th:
• �' eP... i ft. .:Froni::G'S ft.-To:�� ®�c� 5
01'
: " m:"7O .
. . � :. �" Fro .
.To:SgS. .
rom._ ft,
., � F To
�m : Material.: Method. '
Firom:-f�t.To. s ff.To: ft.
''.Fromc: . - �ft.To:�. . . . ft.:To. - . •
•From:_ft,To;:,_ft:� . : - -:: �- . : I :..• � . •� :ft:To:_:::;ft: . . . . _ - � • •- -
From
WaterPrcduction Zon :
Depth: .'�U . ft.. : .f : '
.. .Yield::, • 7_,gpm �ft:.�; � � eft: . : :.�.�.: . �: -
1b thod ofRepair:-:.:,• :
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" "method of Abo omnent : . - " -
certify that this well was constructed,repaire :or abandoned according,to the Guilford Co u
Rules in effect,on thus date and that a copy of this record has been:provided to the well ow ' �Well. .
Well Contractor:A4g....trj„, .. . . . :"
' Certification#:" .yg-.► _.
. . :� � Dates:
.. 1V4}3,'.TtsFT [197S�g{ ;�yt.•• r `i�
Olitr
t:Of Pail
Pump.Installation Company4 I 4r- ,� - : : i
• C._ : Completion Date: '
ft: Static Water Level
imp i3rana: •.:1wt,� � ►�? _ .
� Pump Sipe and Rati•
I hares . . • n ��.
4'elibead
.• g y certify that this pump was installed and completed according to the:Guilfo hp u.�_gpm
Rules in efffect on this date and that a copy of this)record has bean provided to the
rd.Connty.Well -•
well owner.
WcllContractor "
:Certification#: - • • s�
pa : aL
Revised:January 1,2008