GW1-2023-01875_Well Construction - GW1_20230222

i
GUILFORD COUNTY DEPARTMENT OF PUBLIC H< ALTH
Division of Environmental Health,Water Quality Unit
400W.Market St., Suite 300, Greensboro,ETC 27401
ReCord ®f C®nstrudgm, QSPB!ro Or Abandon ent of a Well
Address of We11.7q07 r e7 Gn-�.✓S4a2a '�'7 q SS
LATITUDE 3` �°� �S a
Well Permit Number:: IV J�' 0 7" wl� --6 LONGITUDE '91"0 U�'
Well Contractor Company: a�.! .l1lL ��.. ;,u-� Completion bate:
Total Well Depth:J-ii,5 ft. Well Yield:__Z,S-gpm Static Water Level; 30
ft.
Outer Casing *aterial: Formation Lo
Casing Diameter: K/g' in. Casing Depth: 97 ft, Depth Description
p
Inner Casing Material: From:
From:,�ft. To:_3 ft. y?z-,4 `1
Casio Diameter: ft. T O'_5 z ft•
g in. Casing Depth: ff. Frorra:y)- ft.
G'
From: ft.To: ft.
Grout From: ft. To: ft.
Depth Material Method From: .From: To: ft.
From: ft. To: ft. From: ft. To: ' ft.
From: ft. To: r ft.
Water Production Zones
Depth: la ft. ft. ft.
Yield: �g It ft. ft.
pm gpm gpm glom gl?m j 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.
Well Contractor:
Certification#: 6 Date:
Record of Bump Enstaflat n
Pump Installation Company: /9'Ou,* bfL,tLG TvG
. Completion Dat.e:
Pump Depth: 1 5-O ft. Static Water Level: t4 0 i.
Pump Brand: rn"Z 1 fowl �=f� � '3
Primp Size and mating: �_hp
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on ' dat nd that
/a cop of this record has been provided to the'well owner.
Well Contractor: �. L
Certification#: Date:
Revised:January 9,2oo9

SELL CONSTRUCTION RECORD(GW it i Print Form
For Internal Use Only: --
1.Well Contractor information:
Chris King
14.wATERzoNEs I i
Well Contractor Name FROM TO DESCRIPTION
2080-A -.SPA C %
NC Well Contractor Certification Number ft' ft
Aqua Drill, Inc. 15.OUTER CASING formutHcasedwells OR LINER rfa liphle
FRONT TO DIAMETER T�CIINESs MATERIAL
Company Name ft.. �7ft in. 5� tfr
( r 16.INNER CASING OR TQBING e thermal closed-loo
2.Well Construction Permit#:� 7 �7 ��jfl�lt� ��-j�J?]� FRONT TO DIOMTER THICKNESS
MATERIAL
Llst all nppltcab]e xel!cotts1_cttonperm1&(t.e.UIt;Cottnh;Slab Variance,eta) ft. ft In,
3.Well Use(check well use): ft. ft in
FAgn
upply Well: 17.SCREEN
ltuml FRONT TO DIAMETER SLOTSTM THTCKNFSS MATERIAL
�MdcipaUPublic ft ft in.
ermal(Heating/Cooling Supply) esidential Water Supply(single)
riaUCommercial ft• ft in.
OResidential WaterSupply(shared)on 1S.GROM TOIIfATERfAL EfVLL'r.ACEhhn;NTMETROD&AMO[JATter Supply Well: itring r overy ''n Z U C1C
Well: R ft•
r Re-charge nGroundwaterRemediation
r Storage and Recovery IoSalinity gamer 19.SAND/GRAVEL PACK 7f a livable
FROM 1�D MATERIAL EMPLACEMENTMETHOn
Aquifer Test OStonnwater Drainage ft, it
Euperimeatal Technology ElSubsidence Control M IL
Geothermal(Closed Loop) 07fracer 20.DRILLIlVG LOG attach additional sheets if
Geothermal(Heating/Cooling Return). Other necess
(explain under#21 Remarks) EOM To DESCRIPTION{color,hardness,soultock type, Iola size eK
ft. C-
4.Date Well(s)Completed• 7 2 3 Well ID# it. Ft:
Sa.Well Location: GC
� ft. �-It.
(L &
Facility/�O7wner/Na^me + t Facility ID#(ifapplicable) IL ft
,2q-7_�' C t/Sf��1{rQr•'77 (f T iZCt'l�S 1 IL � �`T9� a _t
C a 44 Vt�..Physical Address,City,and Zip ft. ft
�1;IFyrLc4 �� 21.REMARKS <
County Parcel Identification No.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ffwell field,one latllong is sufficient)
22.Certification:
iY W
/a 9
Xmanent or I�Temporary Signature ofCertiffed w Contra Date
6.Is(are)the well(s)dk
7.Is this a repair to as ezasting well: he warl(s 0--)constructed in accordance
E3Yes or 01 0 with ISA NtCAC 02C 0100 a, N<AC b2C.0200,We11 O-{-tenon Standatds and that a
Ifthis is a repair,fill alit lanoum well construct{'"Information and ocplatn the nature of the copy ofthis record has beenprovtded to the well owner:
repair under#21 remarks section or on the back oftlas 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
drilled: may also attach additional pages ifnecessary.
/J l MI
9.Total well depth below land surface: SUB TTAL INSTRUCTIONS�(g
FormtdNple veils list all depths ydiiprent(arample-3Q200'and 2p1003 ( ) 24a.Far All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:_ ,j
If7vater level fs above casing,use + ( ) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: (ia)
1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Ioicction Wells: In addition to sending the form to the address in 24a
12.Well construction method:_ ! t 12 -A--? l �� i� above,also submit one copy of this foim within 30 days of completion of well
(Le.auger,rotary,cable,dvectpush,etc.) construction to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Unlderground Injection Control Program,
1636 Mail Service Cente I,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: -5t h-J- 24c.For Water StI lv&Iniectio i Wells: In addition to sending the form to
the
13b.Disinfection type: j 7-/� Amount ad�(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of En'cP vrronmenralQuality-DivisionofWaterResewrxs Revised2-22-2016