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Home My WebLink AboutGW1-2022-07150_Well Construction - GW1_20220804 Pr11it For"m WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only. 1.Well Contractor Infoor�rma�tiion- 14.WATER ZONES I Well ContmctorName FROM I TO DESCRIPTION cl o d —A6tt. ft. 3 6► tr. �. NC Well Contractor Certification Number F5R OCIGfor multi-casedwells OR LINER f a licableAqua Drill, Inc. M A DIAMETER t THICKNESS MATERIAL Company.Name 0 ft. 5-0 ft. 6 Y4, in. t2 2 1 t.1 C s� _/ 0 9'! r�� /� 16.INNER CASING OR TIMING eothermalclosed-too L 1J 2.Well Construction Permit#: ..f y I t�J/Q�/ j� -�V 13!1 FROM TO DIAMETER ' THICKNESS MATERIAL List all applicable well construction permits(Le.UIC County,State,Variance,eta) ft. ft. i In 3.Well Use(check well use): ft. ft: in. Water Supply Well: 17.SCREEN FROM TO DIAMETER . SLOT SIZE THICKNESS MATERIAL Agricultural []Municipal/Public tt % in. Geothermal(Heating(Cooling Supply) ffReidetial Water Supply(single) In. IndustriaUCoaunercial 'Residential Water Supply(shared) is:GROUT Ii i bon IRO TO MATERIAL _. EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: ft ft. C, a,04. 12JC _ Monitoring Recovery ft ft Injection Well: Aquifer Recharge �Goun waterRemediation quifer Storage and Recovery []Salinity Barrier 19.SAND/GRAVEL PACK if aspiolleable FROM TO MATERIAL EMPLACEMENT METHOD 3. Aquifer Test OStorrwaterDrainage ft. ft. Experimental Technology ',Subsidence Control ft ft. Geothermal(Closed Loop) F- oTracer 30.DRILLING LOG attach additional sheets if necessary) Geothermal(Heating/CcOling Return) ; Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sollfracktyM grain siw,eta) 4.Date Wells)Completed:7 Well ID# 1011 ®G Sa.Well Location: �.6 ft. ft. Facility/Owner Name Facility ID#(ifapplicable) t? ft. 671 0 �.� s��f rZ� fit) ft. ft. � 2022 Physical Address,City,and Zip ft. fw 2L RENIARrt'R I COUnty Parcel Identification No.(PIN) I i Sb.Latitude and longitude indegrees/minuteslseconds or decimal degrees; (ifwell field,one lat/longis sufficient) 22,Certiti _tion: N W s �, 6.Is(are)the weil(s) ermanent or [ITemporary Signature ofCec6fied well Contractor V 1 Date- i By suing this form,I hereby certify that'the ivell(s)was(were)constructed in accordance 7.Is this a repair to an existing well: []Yes or Oko with 15A NCAC 02C.0100 or I5A 10CAC172C.0200 Well Construction Standards and that a Ifthis is a repair,fill out/crown we/1 construction information and erplain tire nature ofthe copy ofthis record has been provided to the well owner. repair under#21 remarks section or on the back ofthis form. j 23.Site diagram or additional well details: 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well constriction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. drilled: SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: . Z•- (ft) For multiple wells list all depths iJdiJjerent(example-3(a3200'and 2(a3100� 24a.For All Wells: Submit this fort within 30 days of completion of.11 / construction to the following. rw Static water revel below top of casing: Cfl (ft.) Division of Water Resources+Information Processing Uni Ijwater level is above casing,use"+" �i g t, 1"617 Mail Service Center,Raleigh,NC 276994617 11.Borehole diameter: (in.) 24b.For Injection Wells: In additi�to sending the form to the address in 24a 12.Well construction method: t t� l above,also submit one copy of this form within 30 days of completion of well (Le.auger,rotary,cable,direct push,etc.) construction to the following II FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) Method of test cQ� + 24a For Water Supply&IniectioniWelis: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of 136.Disinfection type: Amount_ completion of well construction to ie county health department of the county where constructed. Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH Division of Environmental Health,Water Quality Unit 400 W.Market St.,Suite 300, Greensboro,NC 27402 Record of Construction, Repair, or Abandonn ent of a Well Address of Well:Ka 716 Lu�JS re �y 2 r' 1 LATITUDES Well Permit Number:21 -6 ) -e J iti 0 jZ -C-X i,3f� iAJ,C LONGITUDE Well Contractor Company: ��.�c� �'+ �� , ��_• ( ' Completion Date:7"30 2- Total Well Depth:—V-�ft. Well Yield: .3 gpm Static Water Level- ft -- Otater Casing `Material:S D iZ?_ 1 1='i U C- Formation Log Casing Diameter.. in. Casing Depth: 570 _ft. Depth Description From:-aLft•To.-ICN-!_ft. zai CID,11 Inner Casing. Material: From:, ft. ��n,bL Casing Diameter: in. Casing Depth: ft. From;45-ft.To: 2..Sft, j3 lu C Z=-hru a,- From:--ft.To: ' ft. Grout From: ft. To: ft. Depth Material Method From: ft.To: ft. From � ft.To., PnL From: ft.To• . ft. From: ft,To: ft. From: ft. To: ; ft. From-ft.To-._ft. From: ft.To: ft. Water Production Zones Depth: 1�9-0 ft. ft. ft. ft, ft, i ft. ft, Yield: gPm _gpm gpm gpm gpm gPm gpm Method of Repair: f Method of Abandonment: . I hereby certify that this well was constructed,repaired,or abandoned according to the Guilford County We]I Rules in effect on•this date and that a copy of this record has been provided to the well owner. Well Contractor: Certification#:00SD-A- Date: 7'S<y ',2 2- Record of Pump Installation Pump Installation Company._ � -��`_ Completion Date: Pump Depth: ft. Static Water bevel: C-g- ft. Pump Brand:_��S� 1�<'s�iO�._�'' Pump Size and Rating: hp /0 gpm I hereby cerflfy that this pump was Installed and wellhead completed according to the Guilford County Well Rules in effect on a that a�of this record has been provided to the well,owner. Well Contracto . Certification#: J-`�W(n Date: 2 2 RWSOd:January 1,2009 !