GW1-2023-02459_Well Construction - GW1_20230404

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WELL CONSTRUCTION UCTIION RECORD GV -g L Print Form
i For Internal Use Only; a_�
1.Well Contractor Information: )f I
Gary Thompson I{
Well Contractor Name 14.WATER ZONES
FROM TO DESCRIPTION
4418-A /60 ft. "5 r
ft C'r4'c-4o", S'..6ryr-
NC Well Contractor Certification Number n ft.
IS.OUTER CASING(for multi-cased wells)OR LINER(if ap 'feeble)Drill, Inc.
FROM TO DIAMETER THICKNESS MATERIAL _
Company Name 1 ® It t D L f Gr 2c in• 5�}P-Z.1 P1,C
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ter' e
x W ( ~ I FROM TO DIAMETER THICKNESS MATERIAL '
List all applicable null construction permits(Le.(EC Cotmt};State,Variance etc) ft
ft. in.
3.Well Use(check well use): ft.. ft, in
Water Supply Well:
17.SCREEN
Agricultural M cfpaVPublic FROM TO DIAMETER SLOT sea T(I(CKNESs MATERIAL.
ft. ft. in.
Geothermal(Heating/Cooling Supply) Rkesidential Water Supply(single)
IndustriaVCommereia[ ft ft in.
_ i Residential Water Supply(shared)
IrIrrigationn 18.GROUT
NonWaterSapplyWeil: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Monitoring °Recovery ft. ) o ft CrlrleWl e(, r w:{1` {,eye
Injection Well: ft
quifer Recharge °GroundwaterRemediation ft ft
Aquifer Storage and Recovery °Salinity,Bather 19.SAND/GRAVEL PACK Of applicable)
FROM TO MATERIAL Aquifer Test
OStormwater Drainage ft. ft. METHOD
Experimental Technology E3Subsidence Control
ft ft.
Geothermal(Closed Loop) °Tracer
—Geothermal 20.DRILLI CLOGIttSCh additional sheets if necessary)
(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION feeler,hardness,sail/rank type,pram she,eta)
O La
4.Date Well(s)Completed: 3`15 13 Well ID# ft' C f R
5a.Well Location: l ft. Dry
5't;^�tl ct 1 1
IL , _ It
5..��r 1,,,,:A C-4fiOY.+I 14416 B-,-i'PI ldt'✓ 1 c $. it C{ ft I
Facility/Owner Name ,0
FacilityID4(ifap6 asplicable) k to R 3 5 It -
daE"u N54-ktrv�414\tC.. R, ft. ,`_
Physical Address,City,�and Zip ,...7 1...f It. ft.
vt, k `ot•"t�C 21.REMARKS {�.fR 9J 1} L�LJ
County Parcel Identification No.(PIN)
inscr mr,ia n Pcns.--.:'no t�s°r.t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `(if well field,one lat/long is sufficient)
36t l zI Gt r, c 5' <t ly 77a4/7 4 19.
9. 697 t 22.Certification:
w
6.Is(are)the wells)' permanent or Temporary Signature of [ti/fied Well onuactor `�_1
Date
7.Is this a repair to an existing well: °yeS or By signing this form,I hereby certlfj,that the well(s)was(were)constructed in accordance
Ifthis is a repair.fill out Imam well coustrection information and explain the nature ofthe with ofthis Cecord has been provided to the null oC 02C w0ner Well Construction Standards and that a
repair under#21 remark 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
drilled: construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: SUBMITTAL INSTRUCTIONS
(ft2@I0g) ) 24a.For All Wells: Submit this form within 30 days of completion of well
For rrrultiplewells list all depths ifd erent(rsnmple-3@200'and
10.'Static water level below top of casing: •-2 S!�
)i construction to the following.
+^ ( ) Division of Water Resources,Information Processing Unit,
Ifrvaterlevel is above casing,use o
11.Borehole diameter. 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: R o �ti r,! ��r above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) ( construction 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(gum) S Method of test C.grci. t m
24c.For Water Supply&Infection Wells: in addition to sending the form to
136,Disinfection type: �T��a_ Amount: a} the address(es) above, also submit one copy of this form within 30 days of
C completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Envimnmcntal Quality_Division of Water Resources I I Revised 2-22-2016

' GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health, Water Quality Unit
400 W.Market St., Suite 300, Greensboro, NC 27401
ec- rd ®f Corotracti© y Repair, or Aba c l3r l gent 4=f . 4 -..ell
Address of Well: a" t.t Lt 4-e-1.-;N-VI Lk (3c-u:-.�,S'-‘0-r.,e\\,v,e LATITUDE 3 (v Ili )..c .L5a/6/,
Well Permit Number: -' - t N 1 ,�'~
� LONGITUDE 79
aLiii
f
Well Contractor Company: A t,�a t-`
� � �\ Completion Date: a3 L IS'- 13
Total Well Depth: 3`15-' ft. Well Yield:
gpm Static Water Level: '[b ft.
Outer Casing Material: € tiC Formation Log •
Casing Diameter: ' a..S in. Casing Depth: i t b ft. Depth Description
From: 0 ft. To: to ft. Ctre.-
• III ;I.ert°Casing Material: From: la ft.To: ft. DPI 5 t{ a:l
Casing Diameter: in. Casing Depth: ft. From: sa ft.To: r, ft. (.4.34-5i J,y Se,'I
From: les ft.To: ub ft. 61-iht„4e
Grout From:t to ft. To: -nc ft. Gef,..:;•1•-
Depth Material Method From: ft. To: ft.
From: e) ft. To: '1...v ft. (:ern c,„. poi._r- From: ft.To: ft.
From: ft.To: ft. From: ft. To: ft.
From: ft. To: ft. From: ft. To: ft.
Water Production Zones
Depth: `fib ft. ft. ft. ft. ft. ft. ft.
Yield: gpm gpm gpm gpm
gpm gpm gpm
Method of Repair:
Method of Abandonment:
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• I 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.
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Well Contractor: ,64....4Aj, ,,,—.. Certification#: /L l ie-K. Date: 3—/5`—:)--
3
p..riY9.CYl1K,7aA+Wet ah'=:H`.: .,-.6.2..,2+-#. ...4-s,4,:1;-• :z.. ,xsa.,,,,,..,.:.:-.«C 1'..'�'faK'iA`0.$x>.'.1.'+'.:i::'.:TS,•�."iiwRt��TrtM.`,iiJ�R�gM�.+.�W4
Record of Nalliillp ErostaPEate©
Pump Installation Company: a (-4-Q- Dr; ti ,__Lrl-C Completion Date: _3 -2'l i
Pump Depth: caOD ft. Static Water Level: ILI V ft.
Pump 13rand:.r ,.2-)V pt 1-I m-101 -P 1 S
r7 Pump Size and Rating: 3/L1 hp 1 p gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on th' date and that a copy of thi reco has been provided to the well owner.
f , ✓9
Well Contractor: 9 � ��
f� ,�V'�`-"- Certification#: �� 'd� Date: �'"
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Revised:January 1,2009