The URL can be used to link to this page

Home My WebLink AboutGW1-2022-00201_Well Construction - GW1_20221216 M4.F6rhv-.. WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only- 1.Well Contractor Information: Chris King .14.WATER ZONES—. Well Contractor Name FROM TO DESCRIPTIOM 2080-A 0 "- 19) -36 4 'j ( -I ft. I ft NC Well Contractor Certification Number 15.'OUTERCASING(for tilZ ged 'f sOMEE Aqua Drill, Inc. IFROM TO TqD R TFUM Company Name 79 f,- 16 fir[ I in. TUBING16.INNER CASING OR fitedthetmal desed4bon)' 2.Well Construction Permit#-. A Q w070 FROM TO DIAMETER THICKNESS I MATERIAL List all applicable uvil construction permits ri.e.UIC,Count,.State,Variance etc.)a ce, ft. In. 3.Well Use(check well use): ft. ft. In. Water Supply Well: '17.'SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL JAgricultural DMunicipal/Public ft ft. in. 1Geothermal(Heating(Cooling Supply) okesidential Water Supply(single) —f t. ft. In. DIndustrial/Comitnercial. DResidential Water Supply(shared) 71irrigation FROM TO MATERIAL E EMENT METHOD& Non Water Supply Well: V ft. 2() dro-ey I 'RuCtL Dmonitoring C)R--,.ry ft. ft Injection Well: ft. ft. 3AquiferRecharge OGroundwaterRemediation .19.SAND/GRAVEL PACK if appliciih 1 1,01 3-Aquifer Storage and Recovery OSalinityBarrier FROM TO I MATERM EMPLACEMENT METHOD :3Aquifer Test OStormwater Drainage ft iti -lExperimental Technology OSubsidence Control ft. ft, DGeothermal(Closed Loop) [3Tracer `-20:DRILLINGIOG(attach idditioniii'slieets if necessney). "pe,grain El Geothermal(Heating(Cooling Return) MOther(ex lain under 421 Remarks) FROM0" TO DESCRIPTION(color,barftes%sottfrock sire ctz ft. 4.Date Well(s)Completed: ID# 5- ft- 5 P rud, P-6 G IC -6 5a.Well Location: lo e-'' 6anjuik ft. ft Facility/Owner Name Facility]D#(if applicable) ft. ft. r V 'i-N (L ft. Physical Address,bty;and Zip ft. ft. REMARK 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: w ? 6.Is(are)the we][146-rinanent or 0Temporary Signature of Certified-WellZontractorz, Date By signing this form,I hereby certify that the well(s)was(were)'constructed-in accordance 7.Is this a repair to an existing well: DYes or with 15.1 NCAC 02C.0100 or ISA NCAC162C.0200 Well Construction Standards and that. Y this is a repair,ft It alit known well construction inform.tiodei0d�V explain the nature of the copy of this record has,been provided to the well owner. repair under#21 remarks section or on the back of thisform. I : 23.Site diagram or additional well details: k 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-I 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: —(fL) 24a.For All Wells: Submit this form within 30 days of completion of well For mul*le wells list all depths if different(example-3@200'and 2@100 5 construction to the following: 10.Static water level below top of casing: J 6 -00 Division of Water Resources,Information Processing Unit, I Ywater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a above,also submit one copy of this form within 30 days of completion of well 11.Well construction method: construction to the following. (Le.auger,rotary,cable,direct push,etc.) Division of Walter Resources,Ulide'rground Injection.Control Program, I FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type:AT-LI— Amount- O'Z completion of well construction to th'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 I GUMFORD COUNTY DEPARTMENT OF PUBLIC HEALTH Division of Environmental Health,Water Quality Unit 400 W.Market St.,Suite 300, Greensboro,NC 274611 I , Record of Construction., Repairp or.Abandon 'ent of a well i _Address of Well:65-3 C 90 q e fzS' Zd LATITUDE 3_ Well Permit Number: �2.2 W rs,v giz - 00070 LONGITUDE Well Contractor Company: 144 Uig Da dI Completion Date:l2 -6- . Total Well Depth: l 755- ft. Well Yield. -3 d gpm Static Water Level: .S a . ft. I Outer easing Material: S On 2.1 Forinadon Log Casing Diameter. Xcl in. Casing Depth: 7 Z ft. Depth 1 Description From: 0 ft.To: ft. EC-8 C`1n:i_ Inter Ca4nag Material: From: ft.To:f S ft_ 54W4 k Casing Diameter: in. Casing Depth: ft. From:�,S ft.To-1IV ft. 1 WC, / From: ft.To: ft. Grout From: ft.To: ft. Depth Material Method From: ft To: ft. From:_;Lft.To:_2_(2_ft. C CMS 20ra From: ft.To: ft. From: ft.To: ft. From: ft.To: ft. From: ft.To: ft. From: ft.To. ft. Water Production Zones Depth: 10 ft. ft. ft. ft. ft: ft. ft. Yield: gpm gpm gpm. '-pm -Pm gpm gpm Method of Repair: i 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#: ] p Date: )Z ' 6 _a z 8 d 0!`;K10 Y►. Record ®f Pump Insllau®n Pump Installation Company: -..•7 v-o j Completion Date: Pump Depth: 0Q Static Water Level• ft. Pump Brand:_ A-g)",q l rnIsa—P I Ds Pump Size and Rating: Il� Il _ I P��gpm I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well Y Rules in effect on th' at nd that a copy of this record has been provided to th&well owner. Well Contractor_ Certification#: 2 '`r{ Date: 2-7. ��2' Aevlsed:January 1.2009