The URL can be used to link to this page

Home My WebLink AboutGW1-2022-07152_Well Construction - GW1_20220804 PA- !nt Form WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only. 1.Well Contractor Information: I I Chris King 14.WATERZONE9 Well Contractor Name FRONT TO DESCRIPTION 16ro It. 16y It- 5-4,11 2080-A NC Well Contractor Certification Number ov ft. ixl �% /6 15.OUTER-CASING(156i �Vell$) THICKNESS —L=R itfainelicable)- T1 F Aqua Drill, Inc. FROM I TO VHREIM R I MATERmL 16,�l Company Name /1 in. 15�ppZ fLI,C 0 ft. "16.,INNER CASING ORTUBING'(06thirituil closed-loobl'. ": I ,-'V, 2. Well Construction Permit —05L/Ij XJ/4 4)-W Ze FROM TO - DIAMETER , THICEOMS MATERIAL Lis;all applicable well construction pejmlts(4e.UfC,County,Siatg Variance,etc.) ft. ft. 3.Well Use(check well use): fL ft. in. Water Supply Well: FROM TO DIAMWER SLOT SIZE THICKNESS MATERIAL lAgricultural OMunicipal/Public ft ft in. 1, Geothermal(Heating/Cooling Supply) 0-idential Water Supply(single) —fL ft. in. 31ndustriallCommercial Residential Water Supply(shared) I&GROUT.. 1hrigation FROM TO ft IL MATERIAL EMPLACEEMPLACEMENTMETHODMETHOD&AMOUNT Non-Water Supply WWellI- 0 . 10-2 :)Monitoring DRecovety ft ft. e4eme'?) Injection Well; M ft. :]Aquifer Recharge 00roundwater Remediation .19.SAND/GRAVEL PACK ffarij6licible)� --;'Aquifer Storage and Recovery nSalinity Barrier FROM TO MATE" EMPLACEMENT METHOD 3- Aquifer Test C]Stormwater Drainage ft. % i "lExperimcntal Technology OSubsidence Control M ft. DGeothernial(Closed Loop) E]Tracer FROM TO DESCRIPTION(color,hardness,sollfrock type,grain size,etc.) r3Geothermal(HmtingtCooling Return) nlOther(explain under#21 Remarks) ft 6 ft. 6. ft. F<J cll)q y 4.Date Well(s)Completed:.2-/-f-eZL Well ID# 5a.Well Location: 25E 15 ft. ft. t Facility/Owner Name Facility lD#(ifapplicable) ft. ft. Z/'��Daz ek -"77, cl J IL ft. ff Physical Address,City,and Zip ft ft YL..e 2L�REKAMO LA AUG , 2022 ' County Parcel Identification No.(PIN) ! 5b.,Latitude and longitude in degrees/minutes/seconds or decimal degrees: IrgorvnaUan PrMaQzht9 UrA (ifwcll field,one laWong is sufficient) DME503 22.Certification: N W 6.Is(are)the well(s);bPermanent or OTemporary Signature ofCcrtified-Well ConlractDr Date By signing this form.I hereby ceriiij,that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: DYeS or A? o with 15A NCAC 02C.0100 or 15A IMAC 02C.'0200 Well Construction Standards and that a Ifthis is a repair,fill out known well construction information and eaplaitz the nature ofthe copy ofthis record has been provided to the well vell owner. repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well de!tails: 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 construction,only I 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: Jss— (ft-) 24a.For All Wells: Submit this forim within 30 days of completion of well For multiple wells&t all depths irdifferent(example-3@2 00'and 2@ 100) construction to the following: 10. Static water level below top of casing: Division of Water Resource I,Information Processing Unit, Ylvater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: 4o _(in.) 24b.For Iniection Wells: In addition I to I sending the form to the address in 24a above,also submit one copy of this forMl within 30 days of completion of well 12.Well construction method: construction to the following. (Le.auger,rotary,cable,direct push,etc.) Division of Water Resources,Un&rgJround Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centel,Raleigh,NC 27699-1636 13a.Yield(glim) Method of test- 24c.For Water Supply&Iniection Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of completion of well construction to they county health department 13b.Disinfection type Amount:q 1� 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 27401' Record of Construction, Repair, or Abandonment of a Well Address of Well: �� ls,A 1- l yF c% t LATITUDE 3 Well Permit Number. -0 S -6 l j j-Z -p 7-0 LQNGITUD WeII Contractor Company: Completion Date: Total Well Depth: ^ it. Well Yield: gpm Static Water Level: -30 ft. Outer Casing Material: j•�i� 1 Formation Log Casing Diameter. % in. Casing Depth: 0 ft. Depth D Seri tion From: O ft.To:Z_ft. Inner Casing Material: From: ft.To: Z;ft: Lu� Casing Diameter: in. Casing Depth ft. From-2 ft.To:1 j �,ft. From._ft.. To: ft. Grout From: ft.To: ,& Depth Material Method From: ft. To: ft. From. —0—ft..To:,Z(l ft. d ij� -fit From: ft. To: ft. From: ft.To: ft. From: ft. To: ft. From: ft.To: ft. From ft. To• ft. Water Production Zones Depth: ��O ft. ft. ft. ft. ft. ft. ft. Yield: 5-gpm J gpm gpm gpm —gpm t;Pm gPm 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: Certification#: �0 Date: Record of Pump Installation Pump Installation Company: Completi n Date: -� Pump Depth: I S0 ft. Static Water Level: 1.ft. Pump Brand: `��-,�• �1.��p'�pump Size and Rating: hp gpm I hereby certify that this pump was installed and wellhead completed.according to the Guilford County Well Rules in effect on 's date d�a cow of this ecord has been provided to the well owner. Well Contractor: ,c Certification#..aoi'b `"" Date: t - Revised:January 1,2069