HomeMy WebLinkAboutGW1-2023-01056_Well Construction - GW1_20230125 Print_Fbrrrt
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
C11rIS King 14.-WATER ZONES I I
Well ConnactorName FROM TO DESCRIPTION I
2080-A 230 ft. 5,7— ft. j 0�
• fit. fit.
NC Well Contractor Certification Number :35:OUTER CASING for.multi-cased'wells OR LINER tf a ticable
Aqua Drill, Inc. FROnt T DIAMETER TRICIavE7ssi MATER,I/AL
CompanyName ft. fit. �C1 tin• 5f))•z 21 L(/i 6,
/n n/ / t'-7 /� / C[ :16.INNER CASING OR TUBING eothermal closed4bo '
2.Well Construction Permit#f�^-O� (�J 'J_�jG " I/1 o 6 U FROM TO DwMETER I THICKNESS I MATERIAL
List all applicable well constrtcliom permits(i.e.UIC,Cotmry,Stag Variance,etc)
ft. ft. in
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN.
_ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
HAgricultural E]Municipal/Public fL ft.
Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft ft in.
Industrial/Commercial DResidential Water Supply(shared) I&GROUT
Irrigation FROM TO MATERIAL' EMPLACEMENT 61M=0D&AMOUNT
Non-Water Supply Well: ft. '2a it Ccm�lui zoc K
rT
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge DGroundwater Remediation ft. fit.
19:SA1'D/GRAVEL PACK if a licable
Aquifer Storage and Recovery OSalinity Barrier FROM ft.
MATERIAL EMPLACEMENT METHOD
_Aquifer Test DStormwater Drainage ft ft
Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) [31racer =20.DRILLING LOG attacfr additiiinal sheets if necesse )"
Geothermal(Heating/Cooling Return) ;l Other(explain under#21 Remarks) FRot+t fit. TO D-ESSCRIPTION(mlori,hardness,soiUm li a rain sire,etc.
ft
r\ ,3
44:Date Well(s)Completed:/ .22 Well ID#1-0
lJ ft �y O ft -_71-1 jL'c• IF-cc iC
5a.Well Location: '�6, ft 2 C1 5—ft. ' /7-• i
ft. ft
Facility/Owner Name Facility ID#(if applicable) fL ft. 4 BY
3,50(1 Old lore 0-4 _<40 raCcla k ft ft. JAN 9 �
Physical Address,City,and Zip
fit. ft
����a_ ,T') �rt�t�c'si� a1:REMnRIcs .. ,-;.t a�i�+:s� �r��•..�..;r. -,=
I�- rilPlC)i�p� ,a.
nnty Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 27.Certification:
6.Is(are)the wen(s)��R crmanent or OTemporary Signature ofCentfied Well Contract r I Date
By signing this form,I hereby certify that the ivell(s)ivas(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 15A NCAC 02C.0100 or 15A NCAC 02C..0100 Well Construction Standards and that a
Ifthis is a repair,fill out knom 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 this form.
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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: U SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I (R) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(erample-3@2000''land 2@100) construction to the following:
10.Static water level below top of casing: �v (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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 forth to the address in 24a
above,also submit one copy of this Ifoim within 30 days of completion of well
12.Well construction method:_ ` f a �-1� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
I I
13a.Yield(gpm) + Method of test: ( 24c.For Water Supply&Iriiection Wells: In addition to sending the form to
]�`��� the address(es) above, also submit lone 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
I'
j
GURTORD COUNTY DEPARTMENT OF PUBLIC HEALTH
'Division of Environmental Health,Water Quality Unit
400 W.Market St.,Suite 300, Greensboro,NC 27401
Address of dell:35-6 0)4 1-a Pc C.4 54*d;VcS j?) iv (� GATITUdE ;R_
Well Permit Number:�2.2 '6,2 -C.jj oA3 y -0j 0 66 I,®lV�,1rWE
Well Contractor Company:A(3(i A Completion Date:
Total Well Depth:•2 L)S_ ft. Well Meld: Ci -+ gpin . Static Water Level: !�70 ft.
Ounter Cminag Material: 57?2 ,) 1i tl, Fbrinat on Log
Casing Diameter: in. Casing Depth:V ft. Depth escription
From:_ft.To: 'eft. 0 C,
ffnnmie>r Casing Material.: . From: `ram Ft.To:�� ft. 5 ►Nd 17.0 CAL
Casing Diameter: in. Casing Depth: ft. From.-IQ ft.To-•2<, �—ft. &
From: ft.To.-ft.
Grout- From: ft.To• ft.
Depth Material Method From: ft.To: i ft.
From:—O-ft.To:`2 C0 fL &Xlpmd v G/C From: ft:To: %
From:—ft.To• ft. From: ft.To--_' ft.
From: ft.To: ft. From: ft.To: ft.
i
Ashes°lrodueflon Zones
Depth:Uo ft• ft. ft. ft. ft. Ft. ft.
Yield:/i26+ gpm gpm gpm 9Pm gPm gP m Sl�m
Method of Repair.-
Method of Abandonment:
I hereby certify that this well was constructed,repaired,or abandoned according to;the Guilford County We1I
Rules iri effect on this date and that a copy of this record has been provided to the well owner.
Well Contractor: Certification#: 1 Date: 1,2
Record Of pump Enst guati®n
Pump Installation Company: Completion Date: c�3
Pamp Depth:. f�l7 ft. Static Water Level: Iq
hPumpBrand: .L l t7w� � Tarn`1a—P1Dso'�? Pump Size and Dating: p gpm
I hereby certify that this pum was installed and wellhead completed according to the Guilford County Well
Rules in effect on U tea d that a c py this ecord has been provided to the�ve11 owner.
Well Contractor. " Date:
Certification#: a9 ,
f
Revised January 1,2009
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