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Home My WebLink About_Well Construction - GW1_20230327 (33) Print Form WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: Chris King 14.WATER ZONES Well Contractor Name FROM TO DESCRIPTION 2080-A ,?Gc - G'/ ft. / f_::'.f s M ft. ft. NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL Company Name ft. s /�/ in. Gl�Z�1 �(�'C , 16.INNER CASING OR TUBING(„eothermallclosed-loop) 2.Well Construction Permit#:r 2 3 _O l -L.z,it.:1-1 E_C O\ S.~ FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County State.Variance,etc.) ft. ft in. 3.Well Use(check well use): it. ft in. ' Water Supply Well: 17.SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural IDMunicipal/Public ft. ft. in. Geothermal(Heating/Cooling Supply) residential Water Supply(single) fit. in. Industrial/Commercialt. Residential Water Supply(shared) 1$.GROUT Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT- Non-Water Supply Well: ft- CHID�� 1 �v C K Monitoring ft. ft. T Injection Well: ft. ft. Aquifer Recharge Water Remediation 19.SAND/GRAVEL PACK(if applicable) Aquifer Storage and Recovery Salinity Barrier FROMTO MATERIAL EMPLACEMENT METHOD Aquifer TestStormwater Drainage ft. Experimental TechnologySubsidence Control R. ft • Geothermal(Closed Loop) Trace[ 20.DRILLING LOG(attach additional sheets if necessary) Geothermal FROM TO DESCRIPTION(color,hardness,soli/ruck type,grain sus,etc.) (Heeting/Cooling Return) Q1Other(explain under#21 Remarks) o R 5 .. 4.Date Well(s)Completed: — 6-,./3 Well ED# ''& B' .5 G ft ggjtnd ROGC• 5a.Well Location: C1,"�-,r,,,, -.- .. 56 R' /..2y ' LY/(.C2 61Z41 rt)t 1 e ft. ft. Facility/Owner Name Fac #(if applicalile) ft . ft i L� a J i E WT --a- qJ .j 6IG` 5U l i ALI RA _t)1 I,wit O `C - _ ft. ft. 7 W%26,- , i. e ,1",n... • Physical Address,City,and Zip it ft. 21.REMARKS MAR G t >?iv3 County Parcel Identification No.(PIN) ;nf-:.':.!-; "'. . .:.y.,,::::3 tint Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Csl'a'Or"r), (if well field,one lat/long is sufficient) 22.Certification: (fl,i D. •.<1:._, - 6.Is(are)the well(s Permanent or Temporary Signatureo f Certified eu Con for Date tC By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: fYes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a If this is a repair,fill mu lotmssr well construction information and 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 ofthisfonn 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 if necessary. drilled: SUBMITTAL INSTRUCTIONS 2 9.Total well depth below land surface: Jr ( ) 24a.For All Wells: Submit this form within 30 days of completion of well For multiple wells Est all depths if d fferent(example-3@200`and 2@I00') construction to the following: ' 10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit, If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: ir' (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a above,dRA' also submit one copy of this form within 30 days of completion of well 12.Well construction method: //�dr2 (i.e.auger,rotary,cable,direct push,etc.) constmction to the following Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) I Method of test: 5 i hi' 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 e: Amount:/6 O,� 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 GUILFORD COUNTY DEPARTMENT OF PUBLIC HEi LT.H Division of Environmental Health,Water Quality Dint 400 W.MazketSt.,Suite 300,Greensboro,NC 274011 -cord of CorastvuicSi Ent, Rep&&r, ob. Abandonment of a ellg Address of Well: j�,y q _. j s�ti i�r0 l � i C,l ��1�A J . nJ:C LATITUDE 3 Well Permit Number: 23 -0i -�raii!/2-Cot(S.- 7az LONGITUDE Well Contractor Company:/9Qu; T),7t Completion Date: Total Well Depth: /.2 5_ ft. Well Yield: [ gpm Static Water Level: 30 fl. Outer Casing Material: 5 O1'7 21 ,; Casing Diameter: g�/ Formation Login. Casing Depth: 55 ft. Depth Description From: Q ft.To: Cs' ft. S(;r I ner Casing Material: Casing Diameter: in. Casing Depth: Fronr:� ft. To:�'�J. ft. 5 eft)�; CZcs cK b P ft. From: C? ft.T o:C/.2S"ft. Bid From: ft. To: ft. Grout From: ft.To: ft. Depth Material Method From:. ft.To: ft. From: 0 ft.-Togo ft. dap-,P 7 tj c t From: From: ft.To: ft. ft.To: ft. From: T From: ft. To: ft.ft' o: ft. From: ft.To: ft. Water Production Zones Depth: A. ft. ft. ft. Yield: I gpm. m ft. ft. gp gprn gpm gPm gpm 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. WeIl Contractor: � ,.\ /. . .State Number:a0?0 a Date: 3 -23 P.vec A ird of Pump Ensta[ ata®n Pump Tnstallation Company: ; \ ;mac _Dr (' tf , Completion Date: .. �7 } a-3 Pump Depth: 300 #t. Static Water Level: LQU ft. Pump Brand: ir tCs,_,..9 x c, F I D 10 Pump Size and Rating; ' I hp ) D spin I hereby certify that this pump was installed and wellhead completed 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: 7,i�� 7-rf State Number: I Date: