GW1--02764_Well Construction - GW1_20240506

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WELI:_CONS�'RUCTION RECORD(GW-1) •
-
- t . . Pint Form•. .
For Internal Use Only: ;
• :.. 1 Well Contractortaiformittunt . .. • .. .
Gary•Thompson ..•
Wc11 CantiectorNeri>o,:.
FSCRa74 -
;441e-A • .: . .. .: : • '• • ' : OGR /101 n c CA
Fa _
NC WeltCotttractor CertifiwbonNwalxr
Aqua Dril,Inc . IS:OUTERCASING(formalt4e.seawe]L )RLn�R(lf' )
TO_
Co N . . . - - f:.• J SO • IL.-I �.
MATERIAL
. • ; 1QIIVNERCASINGORTUBING( rmldged.hp p
.• '2.Well Con.trt than Permltd: 43')0.T WNHR'004 :� •
Listed applieahre tvrl oonsinicuonpeimlta(le:UIC Comity,S�'Farrmr eta) imam.'It::
DIAtHE7'FR � .:�rg�gq:'.. �
- - '. . ' 3:3.1i411ute(check•W•ell tuts•): . - ' R.. .• ' .. - tt• , :: •Io, . : . :.7. _
•
Water Supply Wells: • • _ • : 17:SCREEN : y
- - Agel°Whual • •-' • • MimictpaYPublto • • '-- • 7nuaa�s MAT ML
FRtt. ro . •ammerst
(ieotennal(Heatit►g/Coolmg Supply),' Residentta1 Water.Supply(s)nile
• tt.
IndustiIa1/Coamaeicial - ' : Restdeadal Water s!tpply(arrayed). _
18.GdtOUT ••
it n.-
Non-Watery
. Supply•Well: '-. • .. . •onitoring --.: • • • • .G2nnen W"t`c.�rr• -
InJeGIon
Recharge. - .. : O(lmondwaterRcsn mGon
. : . :... . Storage.,404covecyr . . - ESwuy Earner' 9-8ANB/GSAI -• • . CIC(if.maca6le) .
Agatfer.Test. • : ro 1,mi►r. Mr-
wcenntri t►rwnron
1.
•
•
•
FQ011i ' • MA
•
•
• • ._ 13Stom►water)3ratnage , •ft !' -.
• '• ; Bsperimintal Tcclnio)ogy-•.: OSubsldence.Contml •'' It • >ti - . :
.. • Geothermal(Closet Loop).: ; ... . •.. ':. ._ . :.. . . .
': .• • . '• - :•.• Z0.DRiLL1NG�(athek lQaheds i< .- '
Gwthcrmel(UurabnP/CooltngBetum) fOthet(expleintmder#21Remarks) _ p (m.r.rodmm.°4 bae.mt■rar,ae)=
• • •. •:. R' R cl
. 4.Date Well(.)Cotoeted 4 .i-9,4' .• • WeU1Dl1 • 5'.: e. :ys it: R • : •
. . '.:sa Wenit oeatton, '.: . 445 ' . .SO • • "&ram
�� 'so,-
.1reriAiti '.'IntkvS : i-iomes . : 5O. "`` LtLIS a " ' '
:,P lIDy/OwaerNaam'•: .- - •. . �ire9t h }2_ r. •. Faoibtyrl?N(ifapppiable)' : • it. •. :. 'L% .
:2008. beck. R Or Stokisdale "2h13s1: -:t:. • ' •nr.• i s -. ..�9„Y t•- Cis.1•
•• 61)1.Icord.: ..: . • t- .1:�1•: .. . 21.REMARI ':' • • . -
Cmmty .
.. : . . : . :• • a:ee1 tdaa�frcadoa No(PIIV) Gi°fd�r�iC
• .sbintitude.utd longitude in d fnutea/reeond.oideamal degrees- . .
',•(ifweU field,o�iu/iang is filim. eit) ' . . - _
" 22 Certiitcatlon:: a
6.Is(are)the wdl(.) Permanent or•OTemporatT.' - - ., of ell Conh.cttrr
�Ila• ay
. .-Iti f6tc a--pair to ian a ..::.. ..By gfiiini this jamb lkeneby ce4 edit:ire.neR(s)xeu(piny)condiirted in acizal ne.•:
xl.tlog.Tens �Ye. at.�No: •-. . with 1,5ANCACOIC.O/00 or ISAMAC 02C 0200 Fell gnsdvc ion S(michaib wiltthat d .
'. -'Ifthlc l4 aiepaplil►I out known welrrnmhrrdloarrtfamrattmr and epteduthe natmvoftha .' 'copal�tl.ra record hashegpP:05dedta the{tcell mragr• '.. ►¢parreatderrl2lrouan6aec11anoronfhabackgflhrsfom4 '".. • • • . � . .
Sttedia weldetail,.
.: : B: & th :=
ll% oftodrtioatil well site details:or well eanstturxmn detar7s:Yon mliYaiso a_. ... . ;:. ifnecessafiy,
9:Total well depth below land so.
ifatx:,
t • •.'SUBMITTA• L liiigTRU ONSS
.Formrrltrpre walls Ilstoll depths reliffavnr(aiompk-3Q200'and ...• _ TAa Isar All wens• )>mrt fpxB4 within 3•0 .
?C�os� - days of completion of wall
10 Stsatic water level below top ofciting- _. SO _
- comshriotion to the follovviag::
. .1 i.St ate r,above iel id use _. dam) ' 'Division of Water Reap Information Processing Unit,
■ram,
1617 Mal!Service Center,Raleigh,NC 27699-1617
11:18arlhale diateter: (tn.) • • TAi.�'olr Inieeti(I.o.W.
rt Weis Ia.
tulditi�'to • '
12.Well conitraction method: ' 'RO3a►r ((11i. ••
(i a miger;rotary,cable;direct pnsi,eta) . .. conehncntm to the foliowinPYg - forty w m' •
the fonn.to the address in 24a
' thl. 'thin 0 days of completion of well' .
FOR WATER SUPPLY WELLS ONLY: ' Co 1 program,
. .: ,
Dieiston of Water Rota
•
-. I636 Mad Service C
13ac YPehi' • � �' _
(gpm), S. : .Method of tent eAtGl i -'
MQ' 24c.�+ur Water tSaaAly&injection Well.; 7n addition to��'
• .. .-•. ..• • :. • the •136.D. ... c :•type:•N�'H'.•o0.„. • .addeess(es) above,_elan:submit one Ccopy of this:1bim Within the days of '
f Amount: 10 0'L . completion of well-constriction.to tint tatinty health department,of the county
yr ere catistruoted.
•
FormG%V-i •NmlhCeioiinaOtpaitmea't'ofHriviionmeiitelQaelity-Dlyteionof*weirRpoercas
Roviiod222-2016

:. . �� : . - -.: : iTlLFORD COU1vT
G
XDBP -
.; • Division;of Environmental Health;Water Quality UnitL : . .. .: : . :
. O'W..Market St.,Suite 300, -Greensboro,NC 27401 s . ::
itett :,.! df eic3Itstisatittlidik I ®1aoE°o'Or-Q[ and® apt Of
Address of Well )CO8 tkLk �'a e t)c' Sio . t . -: B
: luo
Well Permit Number 'aS•ip.77-\kj
ti NR-6 o 421 : . l.® unn . moo® :I ss8�1'.
- Well Contractor Com an . : :
P y 1��11I :, Inc.:In ... Completion Date: I 1 Q_12.9
:Total Well Depth 4415. .• .ft.. Well Yield:.._ ?. m evel
. . . .. ,.. Level: � $` .
gp Static Water Older Casing . -
Material.
0 ft
Casing Diameters( 2S in::.Casing:Depth; GO .1.ft: : Depth : . : : • : •s�q i .:
: . • From b • ft:To
limner Casing . ..:Material:: . • -. . . F lQe�. cU�Y � r
•
�lL
•rom .5 ft.To y5 ft. :. R�trki.Sa►nd�-,�i I .-
- Casing Diameter: S. .- in. :.'Casing:Depth : :
- - . . _ -ft. From..45 ft:To. SO ft. ,(rra�� i �.2_. : - -•
.
. From SO ft.To:4y5ft riariI4e .
- :From. ft To. ft. ' . . .
l�Pth.: . - Material Method From`ft.TO:
- Frew: jt.To::`dO :ft. .
From: ft.To:__ft. _ . . . . ..
• en- � '�ii tit I�r�ck •From.•
-.��From: '� From:. ft To:�ft
._.::ft.To
From
. - : ;Water Production Zones:: : : :
Depth: ZE ft.:: - ft, : ft. ft. -
Yield :=�gpm ' :' : ggrti . . ----�.� - :ft.-.-. . - - . . - ,:ft;. : :�... .
gnu ' gpm :L gpm. :_ m: •
Method of Repair . : •: :
Method of.Abandonment: • : .
I hereby certify that this well was constructed,repaired,or abandoned according to the Guilford:County Well :
Rules in effect on this date and that-a copy:of this record has been provided to the well owner:
.. .Well Contractor: :;4w_7 • : Date: 4•• Certification#:; :. a�- _ - :
ROcora ©f P_ u im ElmO{ta08Otere
mp Pu Installation Company: . � a. l I �/
�� Completion Date `'���- . .lie...l 4
.Pump Depth: ... � u�. ;'ft...Static Water Level: .620 ft..
Pump Brand: �v.�,;,,a,. - - - :�
Pump size and Rahn : -
g. . hp. . -J.� gptn. • i,
I hereby certify that this pump was installed and welihead.completed according to the Guilford County Well I
Rules in effect on .. . � -
._. . ... an that a copy of this:record has been provided to the well owner.
Well.Contractor:: - -
'� 12 / Certification#:019r140
_'. Date:
Revised:January 1,2009