GW1--02760_Well Construction - GW1_20240506

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WELL CONSTRUCTION RECORD(GW:$1 . : • For . •.• •� -
tint Fa_ reel. ."
Internal Usee Only;
-. .1.Well-Coutriac6or Intarmation: - . . .
Gary►Thompson • - • - _ - " : - -
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�.weT�ezoN>rs� .
. .. Wa11 Ccatraotorxamo. = : .� .
' 441e-a .. 954 S21 [
NC WeU ConueotoTCeihfigtWn Nom6er: . . . . .-
a►r��ot; "3 �fH
Aqua Drill,Inc,.. is.OUTER T TO. ••' .mnl "�')OR LINE-R SS'" eiar
CompanyNaam• ....
, ` -" - 0:••tt. I.ge :fib:I. -
2 4ell_e0MIER IIORiicrmit1P.3r.10 W : ..00-1a►.1_ . OR1i1B• lABIEI Ri ' : • • '
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FROh1 t PIING. ..
List all appilcable xell'canstr citvripermite(i.e;UIC,Comp.S azc,Variance,.erg) • .. -ft* �y. ; ' •' '• • _
. •3.Well Usti(checkwell uce): : " . - -
Water Su " Wele
..- PPS' - .• .__•_ ,. ."• "-." 17.•tiCREEN•: ..
. .'.. Agdcuiturei :: . : '• ' :' : •. -. " •• FROM -To - :
.. . • QMunioiPOPuhflc • . : •• '. :i .
Geothermal(Heating/Cob, g � n mar�- s[.v� '
" �*pit') " ResidentielWa�rSu t� .
pP1y(fie)'
Ta[cuxFss .
IndushdaUCommemiol. - .. bbi Q' - In. .
atert3nPP4Y(811 1
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- Irt�iaatioti'.. "
dentist 1N
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......,. :,..... ...:•.... .. . .....: ..._.i.. : •:... . •.-.• :. .-.... . .._ •. •
Non=Water Supply Well.
. . aGRouT ".� :-
FRaar TO. IMATt i�lereritn.is[onamttomvi�:
In(eetfon Wen:• ": .. " = '
: .• • .. : ' Oroundwater,Rem tz ". • .. _ ". •: -
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f AquifersmlBgewidRecovery DSalultyBanier 19 RAvELPA bras. ui)
AgwferTest . `'" •'." Stoanwat� To ► 't1E'ison. "
FRoe1.
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. • .. ".. . � Drainage" . '. . :. :.:ft..:. R BEATER/AL. _
Expeilmental Technolo ' •. .; 8Y.: -. �Sutisitlence Control:•: .
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Geothermal(Ciooed Laopp):'.: .-- �Ttnce '
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" Geothermal(Heat1ngiCoolingRetam). 0othcr(expiaialundcr##ii Rem) PRO • t ter. q,P,
4.Date Well(.)O nipleted fla-aq WeIflD# b' . .�, " •" call `'3�t; ."1 G1 .
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9t,.WeIlLoiattotle : " Root sbq•,•.
: earn• cgers alo me5.. . . • -
t olIdylOweerNeme ..• Q
-FacilityIDOpfappi[ca ky 8•. f1. 11.1c.
ft; '
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t@1i1"I"�
"'�t3 .�OC. Qi C . S okes1A a i 13S'�. - 4- Z,.,A •` c..-: l• n ; ' .
. . • • REIVL+RICB
.. comity. .•• ' .. - . . - . • - ..
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. PeroelTdcndfieatcon No.(fIIQ
56.Latitude i it to
'f><��d+�eeslminuteehwnds or dedmal degrees: ;:. .. : �
Gt�a( r vrq
+..4 (IfxroD9kldr oaa LUirmileeofllciete) ; . . • .. . . : .._ I
` . `i o ` x► 22.Certlftcaaon: I I.
"36 1�1i.o " w. • •• - :. •
6.k(are.)the wdd(s) Pe ubuiot or'ID'1'emporary ,si of wad
t+aor ��
rifted i
- 7.• thv a • ao On -" '..• . . ' :BY algid th1;P. 1 hereby 070.4 r�he,�ll. : i
• repliM expongwe : uYee or No'' • with ISANCACO2C.0100orISANCACTO:0200 Well Cbra'sdvctto.Seated In acaoMance , :..
. lj'fhii irdiepdf JJtrouriamVnwall oomJrtteilon Bear riton and eiplafn the aaharojtbe �pY,olthlaTP2111 barlreea St::.. .la and. :
•" ,. +2palrn�er#Ilr�am6rleaacttan•oroalhabackbflhLrjoni. :. - - •- ..N [al6e,umllaiuner." .. • .
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8.Fri Geoprobe/DPT or Clositt•Loop ' " -
' Stt®dtrtgrttm or eddnFonal�demQs •• t^�thermal Walla Navin the dune . Yon�Y use the back cf this page tb provide
'con.thiction,'onl 1 GVU 1 isorrd,ed Y Indicate TOTAL NUMBER of wells cosht:otion details, Yon magi also sasi:h'addtioaal � 11� • • '
.drille : . .. . ".. - . . " _.. -. • . . • • agasifaecoasa[y - -
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BMITTAL UBINITTAi.l4V � ucrroNt:.�
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9.Total well depth below land surface:. is
ForinaldplewellrllstalldepliW itSj8epiefemeydez3(a)?00'and20/00� ( 4 24�• or•All Willa:• Sbbmit•this foam withm:30 days of completion of well t
' � ,. � . - to•the.folloavmg•
10.Static water level below top ofcasing
. . oonshuction �
(1'i.Stage
evel ti above aarl el sae +" .. - •• '(ft.) Division of Water Resources,into"ra soon Processing Unit,
11.Borehole diameters. - 617 Mal ServiceCenter,Rahlgh,NC 27699-161
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.. b:�o lectt Went: m w Jltionfto sending 9:e form.to the address ia;24a
za r.x •
above,also submit one
12.Well eonsfr talon maned: • RO Ovi y. • Art . . copy of this- -1 within: • days of completion of well
.( ,rataig mbia,di:eotpita&eta) - " - : -
• t�nshuc:rion to the following:
FOR WATER SUPPLY WELLS ONLY• •DlvWon of Water Resources,Uadersraund lojectioti Control Program,.
: : 1636 Mail Service Conti.RalefiltiNC 27699-1636 -• • • '
13a.Ylelii m S.ethod of t �id1'�G11
• .. � ) : � � �'Time •T,4c.Yon Wofar l�oaaty di•inl¢etlon Wdlt+: In addition to sendiog.thefaum to
1'•'D1l.-.. ton typo:. e : • -. '. ' the addresses) above..also submit:oti
14�F1- ••b% Amount -16 07.. SPY he is a-Onto within 30 days y
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completoh of well,consttt[ction to,the county h department.of the couety
where constrocted:. li: : .
• FoimOW-1 North.Caro]inaDcpmiment ofi?nvimmaenfai•Qoality-Divieloriof Water lb:saurus Revised2,22:2010

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GUILFORD.COUNTY DEPARTI NT••OF PUBLIC HEALTH:
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T)ivision•of Bnvirontnental Health,:Water Qualtty.Unii: _: • ::.. : . , : . ::.:.
: St.;:Suite'300,.Greensboro,NC 27401 • '
� �400 W.1Vlarket
.: . : �6�o� ii ®f ��itit.t_9©�© :b1062pdteo Or. bili 1.6 Bi'9 _
Address of Well:.dO13 �G�.F �� �� : ,i
S 6<6t�a le .a1351 � iYui6E A.
'Well,Pernut Number ' .•�a3 i 0,=- N -� � 1....31. O
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R
d
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��o�a� ��®NGIT��E . •
Well Contractor :`1HG .. S
. : Company: �ua:�Dr �� • � • ' Coimipletion Date y'13 .4..: : .
.. . :. - '.Total Well Depth:. ..bas : .�. -..
• Well Yield; : gpm Static Water Level .•.' ®afar C� � . . � .
g• � Material: PV CG
. .• . . . ..Casiip Diameter. � ' . � � • � .. .
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-.Caging : b•aS•,in: .Casing Depth:. :$$• • ft. . . ... .Depth'. g+®
ri
From. O. ft 1I ft.
Desc
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limier Caking Material From::I 1 3 �e-1 Diprttio.
Fs1S ..
Casing Diameter: :. . � . . .. �: ft•�T:o eft: S ►rd. :QeckY:_�`,�I�.- :.
Cas _in. Casing Depth ft: :From:-83° ft::To:eft.. :-6.com :1e:.:. .
rom:9ft:T • :ecariNe . :
�� Material,. •
From: R,.
. :Method
. From: 4. :ft.To: �1t7�ft. � Cement.. From: ' • :ft:•To .•ft:, : .
nt.. Pour ..�Ilr%e k•From_ft:To:_eft.:
. : - • From_: f.•To:_. ft, : . .
.From: �. . ft:To._ft.. . • . :From. ft.To:: -:••• :ft::: .
. . ' • . .:. . •Water.Production Zones: - -
•: .Depth S135 ft. :. . ft. :
ft. . ft. . ._. ft.
. Yield... � . . ,.. .. • .. '
.. gpm
. gP bPm
Method'of Repair; : :.
Method of Abandonment:. ::: • ,.•. ..• .'.: .. • :: ' . .
Hereby- �I i:ertzfy.�that this:Well Wes � . . . ..
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as constructed,repaired,:or abandoned:accordin to the:Guilford:County Well. . :.: .• -"
- -Rules in effect on this date and that.a copy this record has been provided to the.well'owner... � • •
Well Contractor: : . . . .. . . .. �.
a on
'i18;°A• • .Date:Da 4 ,.ia,.ih•1
• • `Pump Installation Comp an ; ti•( V. C. Completion Date• : -a_ll- 'a4
Pump Depth: -. C - ft:•Static glaterLeVel: tab . ft. •
Pump Brand: rv►.�� • • . . . , ;
Pump:Size and-Rahn hp.__ dPth: ...
Ihereby certify that this pump was installed and wellhead completed according to the Guilford:County Well'''..
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-Rules in effect-on thisZJ?
and that a copyof this:record has been provided to the well owner. - : .- #
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_ Well Contractor: -/� � � �
Certification#:cl�'t` Date: . /7/2 9 '
.....____,.._,_ .Revised:January 1,2009 . • ,