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Home My WebLink AboutGW1-2022-08087_Well Construction - GW1_20220826 Print Form ._,' WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only: --- 1.Well Contractor Information: Chris King 14..WATER ZONES WellConiractorName, FROM T ft. DESCRIPTION 2080-A ft y31 ft U 1 tt. NC Well Contractor Certification Number R OUTER CASING foi multi cased'wells;ORLINER if a licable' Aqua Drill, Inc. FROM FRONT TO DIAMETER THICKNESS MATERIAL ft.Company Name {vo ft. 1 �f p �y�ey/ -.16••INNEXCASING ORTUBING eothermni closed•loo - 2.Well Construction Permit# ate CGS tYT1�C_J��1�o FROM TO DIAMETER I THICKNESS I;MATERIAL ^ List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.) ft. & In. 3.Well Use(check well use): ft. ft. in. Water Supply Well: '17.,SCREEN - -- FROM I TO T nrAMETER I SLOT SIZE ITmCKNESS MATERIAL Agricultural E)Municipal/Public h fL in Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fit. ft in htdustriaUCommeroial Residential Water Supply(shared) 18GROUT -.., ...�`. is=. :. ,- ..-••-. .. ..t;. ' te Non-Wate FROM TO MATERLIL END'LACENEENT METHOD&AMOUNT Non-Water Supply Well: fit: �F Monitoring Recovery ft. V ft. Injection Well: ft, AquiferP charge oGroundwaterRemediation ft :49 SAND/GRAVE-PACK ifit licable Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEM E NT METHOD Aquifer Test oStormwater Drainage ft. ft. JE.xperimcntai Technology Subsidence Control ft. fL Geothermal Closed Loo Tracer ( P) 20:'DRILLING LOG.attarbaddititinal'stieeCsifnecessa - Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnem,soilkock type,grain size,etc.) Q ft Cg ftkre 4.Date Well(s)Compieted.9-1Z -2 Well ID# (4 ft -qS 5a.Well Location: I3-5-IL 7 49 tf ft. fL Facility/Owner Name Facility IDA(ifappplicable) ft % 172615- t Nam) ft fib PbysicalAddress,City,and Zip ft. ft. t._d J k 1 r0 iZ 21.'REMARKS:. County Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field,one lat/long is sufficient) 22.Certification: 6.Is(are)the wellO Permanent or fOTemporary Signature of Certified Well Co for Date By signing this farm,1 hereby certify that the ivelf(s)was(were)constructed in accordance 7.Is this a repair to an existing well: I Yes or,8N_0 ivith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a If this is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to.the well owner. repair under#21 remarks section or on the back of thisform. 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 addition l,well-,sit"etaiN161:��'"g construction,only I GW-1 is needed. Indicate TOTAL NUMBER.ofwells Construction details. You may also attach additional pa if nbcssYai} i drilled:' '�e To 4.Total well depth below land surface: C/ fJJ- SUBMITTAL INSTRUCTIONS �' r 2 J 3 12. 6 6 O^[L (f0 24a.For All Wells: Submit this form within 30 days o completion of well ijdifferem(example-3(rr)200'and 2Q100) For multiple wells list all depths construction to the following: �. r 4�. 'l 10.Static water level below top of casing: f>: ltltv''ti Urel ( ) Division of Water Resources,Information Processing, Ifwater level is above casing,use"+" 1617 Mail Service.Center,Raleigh,NC 276994617 11.Borehole diameter: (in..) 24b.For Infection Wells: In addition to sending the form to the address in 24a 12.Well construction method: /7 j_[ above,also submit one copy of this form within 30 days of completion of well (Le.auger,rotary,cable,direct push,err.) construction to the following. FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) ld Method of test:51 24c.For Water Surmly&Infection Wells: In addition to sending the form to 2� the addresses) above, also submit one copy of this form within 30 days of 13b.Disinfection type: ( _ Amount: completion of well construction to the'!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 GUI£.FORD 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:?-21RY / )cs La a, ,—t-4 Cj c LATITUDE 3 Well Permit Number:-9 G-D(-Gs yrJ iZ -D 6 O ou-C LONGITUDE Well Contractor Company; f) Completion Date: z - Total Well Depth: �1 C _ft. Well Yield:�gprn Static Water Level: 5 0 ft, Outer Casing Material:Sly Z 2 t ]formation Log Casing Diameter:C j in. Casing Depth:Z�I O ft. Depth Description From:O ft. To: � ft. fit! Inner Casing Material: �_ .I.35� 5i ," From: ft.To• ft. ��P., �, Casing Diameter: in. Casing Depth: ft. From:V:5=- .To:��ft. )3 j,•zf G� From: ft. To: ft. Grout From: ft. To: ft. 0� Depth Material Method From: ft. To: ft. From ft.To:.J2 _ft. u From: From:—ft To: ff. Frvm: ft. From--ft.Tb; ft. From: ft. To: ft. Water Production Zones Depth: 1/30 ft. ft. ft. ft. ft. Yield: 2 0 gpm gpm gpm gpm gpm m gP 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#: O �O Date: -JZ- 121 Record of Pump Installation Pump Installation Company:__ 4L"11 �r► r Completion Date: Pump Depth:- — ft. Static Water Level: Pump Brand: 52-1 S--"�J� Pump Size and Rating: L`�hp gpm I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well Rules in effect on thi to d that a co y of this record has been provided to the we]1 owner. Well Contractor: C Certification#:! Date: Revlsed:January 1,2009