GW1-2021-00142_Well Construction - GW1_20210305

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m3 F L7L C0NSTRUCT 10N jEggR D(gM Ll1) For IniDrnal Use Only:
J.Well Contra ctarr1 Informatioo:
.14--wA7RR7ON&!
Well CoatrzctorName FROM TO D]SCrilPxrON
303L q ft fr.
fr.
NC Well Connector Cetrtfieatiov Number IL
15.OUTMUC.ASMG fdrmulfi-ea'ted ideffs'ORLINEh rff"• "61
Yadkin Well Company Inc, FADM To nrerasrRR TmC,msss MATmvAL
Campevy Name ——. ft.
e6
3.Well Construction Permit g:
.16.'MNRR_0KSEAG0RTUBMG Nie''®ileloYedlo '
PADM xo ➢rAMAT'sa THICe¢YPSS � •MA]BRiAI.
List o!l vpplicob(e well construc�ionpernrim(r'.e.OfC.Cornty,Sane Ya,ian e,etc) !ft el 2 (/Y rv, 5
Pv
l 1
3.Weld Use(check well use): g ft in
Water Supply Well: '17.Sl;RR:H19`';�MunicipaUPublic .':.
A cullnial FROM TO DI NX6 SLOTSIZ6 TnICIDYF3S MATSRIAr.
�
_ Geothermal(Heating/Coohng Supply) Residential Water Supply(single) Q R ft iv
fi e.
rtmria1lCommucial Residential Water Supply(shared)
ficri
te _ FROM TO MLTCHiAl EWIACga'[�yfM OD&AMOWT
ter Supply Well:oringRecoveryqqn Well - - oCr Recharge ©Groundwater Remediation ft. Z
r Storage and Recovery ©ISalinity Battier - ' 6VSL'FACKff able FROMr Test OStormwater Drainage ft fe
mental Technology Subsidence Control ft
rmal(Closed Loop) DTrace, O:Dun"*`^1,OG`s¢iek'eddifioriel sheets ifne¢ss'- -
_ Geothermal(Heating/CoolmgReturn) EOther(explain under#21 Remarbs) mom D�C'niPITON(mtur,baNvm,sn,'V ey . ..s�,ek -
ft ft t
4.Date Well(s)Completed: = -�_ Well ID" 0—33 R �R .L
52.Well Lo``c'ation: phone number fL ft
Y-t4L I7rJ eS'1<, ft ft --
Facility/Owner Name Faciity ID:(if applicable) ft. ft
J- ft, ft
l
Pcysical Add..,(ity,and Zip at. ft
71:REMPst Ks.' . .r"
Ce'9h' Percel ldcvtificedon No,(PA7 /I s
5b.Latitude and langitude m degrees/minutes/seconds or decimal degrees:
ff ll field aae lat4ongis sufficient)
22.Certification:
6.Is(are)the well(S)RfPermanent or IBTemporary Slgnffiure tUcmtadWdICznff.a, Date
By signing rhu form,1 hereby co»fy thin the wells)was(were)mmrrvoed in aeem-dmme
7.Is this a repair to an eristing well Ayes or �o noel,15A AICAC 02C.0100 or IM NCAC 02C.0200 Well Conrtruoiar,Slmdardr and thm o
ii this is a repoi{fill out known,rdl consrrucrimr it f rmarivn rued ezploin the nature fee c„y ofrhis record has been provided m the well owner.
,under$27 renarkr section err vn the barF.jmisj rm
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
consvucdon,only IGWA is needed. Indicate TOTAL NUMBER of wells Construction details. You may also attach additional pages ifuecessary.
drilled:
n SUBMPITALINSTRUCTIONS
9.Total well depth below land surface: _-zU -L
- For malt le w•e0sllmaA oe du'd ( p @2 l^31 ) —(ft) 24a. For!ill Wells: Submit this farm within 30 days of Completion of well
'P p 7 rBerna exam le-s oo'and2 00 construction to the following-. y p
10.Static water level below top of casing: L (+ _(fr.) Division of Water Resources,Information Processing Unit,
ifwmerlevel it abm:e mmHg,use"+" Division
Mail Water
Center,Raleigh,on rocess1617
11.Borehole diameter: C Bit off `\
24b.For Iniection Wells: In addition to sending the fo na to the address in 24a
12.Well construction method: ` !. , above,also Submit one copy of this form within 30 days of completion of well
li e.auger,rotary,cable,directpeek,etc — construction to the following:
FOR WATER SUPPLY WELLS ONLY: -- Division of Water Resources,Underground Injection Control Program,
l _ 1636 Matz Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) -�( (�' Method of test: _ V 24c.For Water Snnoly&In" tin Wells: In addition to sending the form to
CUPS Ile the address(es) above, also submit one copy of this fame within 30 days of
136.Disinfection type: HTH - Amount- f completion of well construction to the county health department of the county
where constructed.
-^®GWd Nmrh Cazoline Departinevt of Emdromnevtal Quality-Division ofwator Resources Revised 2-22-2016
Date Smote V2S7_

°—co&' Environmental Health Division
Water Quality Section
400 W. Market St.
Greensboro, NC 27401
�r [phone]
� inH►
Permit to Construct a Well
Address: 6617 KOALA DR, OAK RIDGE, NC 27310 Permit Number: 07-05-WNHR-03611
Comments/Specifications:
Well shall be located and constructed according to North Carolina and to Guilford County rules.
Well site must meet minimum separation distances.
Above Information Certified By: '2LU Date: 12-15-20
Owner or Authorized A ent
Permit Issued: Date Issued: /P -eq-ao
ental Health i
I certify that a grout inspection was completed and is in compliance with Guilford County Well Rules.
Partial Grout Inspection: Date:
Environmental Health Specialist
Final Grout Inspection: Date:
Environmental Health Specialist
Permits for the Construction of New Wells shall expire one year from date of Issuance.
• All property lines and corners shall be clearly flagged prior to construction of the
well.
• All proposed structures shall be clearly flagged prior to construction of the well.
NewWellPermit Page 1 of 2