GW1-2022-07147_Well Construction - GW1_20220804

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tUt'lrlIGRIBI UJG Vniy:
1-Well Contractor linfortnaBion:
Reuben ben W. 1ti BQrATEtt�OP1E�
WeIiCOntractprName FROh9 TO DESCRIPTION
2241t 2 4c ft- 2-
NC Well CoritraotorcertifcatioaNumher ft. I
6"3�Aqua
y B�pp NIL Inc. 5.OUTER CAST formulNcased�relts ®li1,IIN�R Ifm lica_
FA tJ�PFlUg 0 0b FIiOii TO D TMCICK S BUXIER1AL
CornpmryNwne jp
�� Iey. fL f i' iir, S�eA1�yr1 �,
2.Well Construction Permit _® `�/7e Q 7 I6.flNNE4tCA i1NC OttTiii3 0 cotbcrmaf closed-Too 1
FROM TO DiAn9E1ER. TMCKNESs h9ATERGIL
LLcr all w"cable mall canstnrclian permits(l e.U1C Coulay,state,Irarlanc4 ua) ft fL in,
3.Well Use(check well use); ft qt ir,.
FAgficultural
y Well; 17.SCREEi+l=T0MWUa2M-1jR. SLOT SIZE TNICKtdLSS hfATErtAI
0� icipal/public(Heating/Cooling Supply) _ Residential Water Supply(single)
industrial/Cammercial [Residential iWater Supply(shared) f0.����
(lltrigatian rnont TO 11TAT uuat; rJurr�eSn olrnnexRaDEnniovnr
Ikon-Water Supply v71r11: ft. _ �
...ilvionitoring of ecovery 7—/U;
lnjeetion ell: .
JAquifer Reellarge, Drroundwater Remediation tt'
IAquifer Storage and Recovery 19.SA MIGRA-IEL PACEL(if a liCtble
rY iSalinily Barrie► rttonr To nrATERrat,
'Aquifer Test Eh9PLACE[t9ENT99EdROD
Stonnlvater Drainage ft. ft. r
Experimental Technology 01Subsidence Control ft ft
ElGeothermat(Closed Loop) 0,Tracer I'
EO.ISItILLINQa 1.(BG(ultacTt additional`sheets if itccssarr
Geot-terra-{Heeling/CooiingRetum) Gther(explain under#21 Remarks) Frtonr TO DESCRIMON catu. soo/met;ev,r en,;ns�e ore
0 ft IL W
4.-)ate 111dl(s)Completed; WelI M/r ft
f? i��✓ � ,v�SvGo�i
32.MJell Lorntion: 13 a fr. j� s T
/5i' .�GC^!/Crir�G ,i ftL j fa iiJ/�✓�i�C�/ �'��.1�Z�.,y��
Facility/0tvaerNam: Facility ID9(ifappticable) t C fF
��
PIr}Steal Address,Crty aaa ztp (� ^ ft. ft .,, �e L.. g
CQI
LA 11.—REMARKS
County Parcel IdentiticallonNo.(PIN) C 3 L
sb.Latitude and longitude in degmeJntinutes/seconds or decimal degrees; til#ar�l fLxO Pf�ct iltg Urt
(Nmil rield.arc lat/long is sufticica0
21^.cr l'u•cation:
01
6.Us(are)the-ll,,,ermanent or DiTemparary Sieaature OfCcniGed Well Contracto ate
By signing rills form,1 hereby cen'Ib that Me well(s)eras(rare)calwnicted in aceordmlce
7.111 this a repair t0 an existing-veU; Dyes or .' r4o mldr 15A NCAC.02C.o100 or 1-SA NCAC 02C.0200 trail consiniction standard,and 111at a
ffthlsLcarepatrfillomGntnearse/leansrructlanbfnrntatlonmrdlrplaintltenatutirJdte �pJ'afrbisrecardlrashrenprovldedtatbeirerlmurer•repairander l rentarkssectlan or on die back ofdN.sfnrnt.
23.Site diagram or additional well details:
S.For GeoprobeMPT or Closed-;coop Geothermal Wells having the same You may use the back of this page to'provide additional well site details or Well
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if nears dnlied: �'.
1 SU11oP✓31 '-AL I1p1S'l'RU1C'P,TONS
9. below
Harm llWcll depth all
land surface:_ (€) 24a.For All Wells: Submit this form within 30 days of completion of-well
Formultiple rvelfsllst all depttrsifdiJfernnt(ecample-S@200'mu12QiUU')
construction to the following:
10.Stake crater level below lap ofcasing:
ljxWtcr level is abolr casing,use UP 9Bi°rision of Water Resources,Ilnforniadon processing Unit., .
"+'
1617 Plait Service Cen0r,;,Ra1e%h,NC 27699-1617
11.Borehole diameter: i5F
(in.) 24b. a dniection d'Uells: In addi(iot to sending the form to the address in 24a
12.Well construction method:_A/�_C- j y1y'.-1j above,also submit one copy of this fonn within 30 days of completion of-cell_
0.e.auger,rotary,cable,direct push,eta) construction to.tho following:
i
E'OR WA71 ER SUPPLY"vt/D.LLS ONLY.- Division of WaterResources,Underground Unjection Control progParn,
1636111lail Service Cerill�Bafleigk NC 27091636
13a.Yie(d.(gpm) q Method Of test:C;?✓G!✓yY)Al � rise,For Water sunniv&ilniection W' ells: In addition to sending
r the form to
the addresses) above, also submit one'copy of this fore within 0 days of
13b.Disinfection type: �v�/�!�j// Amount. �eZ, �}7_ completion of well construction to the county health department of the county
where construcled. i
Fork GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 3-22_301G

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W.Market St., Suite 300, Greensboro,NC 27401
Record of Construction, Repair, or AbandonIIment ®f a Well�L j l
Address of Well: ��y6 - l �Jdlr�i-c-�� 0064 `ss LATITUDE 3-4�y zif '119 ,L�j�'�
Well Permit Number:/ d -�✓stJ ���yl(� LONGITUD€ ZZ Y�c
Well Contractor Com an : u� 4. /� ""�� '
p y ���� Completion Date:
i
Total Well Depth: 6�ft. Well Yield: _gpm Static Water Level:
Outer Casing 1�Material:-5e-A 2-1 Azi1 Fora ation Log
Casing Diameter:--- -_in. Casing Depth: _/�.�ft. Depth Description
From: OF ft. To: �' ft. �
Il><nner Casing Material: From: '� ft. To:Zy ft.
Casing Diameter: in. Casing Depth: ft. From:„�a_ft.To: 53 ft 4VL,7
From: ft.To:& ft.
Gg'oaat. From: ! ft. To: ft.
Depth Material Method From:
From: 4Z ft. To:-2-'lft. .��cic,dca- i �i< rJ�QFrom: ft.To: ft.
From: ft. To: ft. /��S From: ft.To: ft.
From: ft.To: ft. From: ft. To: _ ft.
Water Production Zones i
Depth: ZAP ft. ft. ft, ft.
ft' ft.Yield: ft.
gpm gpm gpm m
gpm gpm gpm
Method of Repair:
I
I
Method of Abandonment:
I
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: /� I "—` Certification#:,?f Date:
Coll
ReCord Of Pump Installation
Pump Installation Company: , c� �`, 1 C✓ Completion Date:
Pump Depth: ft. Static Water Level: I ft. �N—T---
Pump Brand: ��o���e o��s11> - f�'I l�iC� Pump Size and Rating: _hp d Q
gpm
I hereby certify that this pump was installed and wellhead completed according to lthe Guilford County Well
Rules in effect on th' date d that a opy of this record has been provided to the;well owner.
Well Contractor: ' Certification#:12�ft- Date--�--22--
I
Revised:January T,2oo9