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Home My WebLink AboutGW1-2023-02460_Well Construction - GW1_20230404 Print Form WELL C INSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: Gary Thompson . 14.WATER ZONES ' Well Contractor Name FROM TO DESCRIPTION 4418-AD ft y g' ft' F� ��ro� ''�S-Grr' ft. ft. NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if up livable) Aqua Drill, inc. FROM TO DIAMETER THICKNESS MATERIAL Company Name (:, ft. c4i ft. 6,a s in. 5 D Z �r)l v� }�� 16.INNER CASING OR TUBING(geothermal closed-loop) I" 2.Well Construction Permit#: 'b i`LJ is(k-( ) 3 FROM TO DIAMETER THICKNESS MATERIAL List all applicable unit construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in. 3.Well Use(check well use): ft ft. [n Water Supply Well: 17.SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural OMunicipal/Public ft. ft. in. Geothermal(Heating/Cooling Supply) residential Water Supply(single) - ft ft in. Industrial/Commercial E3Residential Water Supply(shared) 18.GROUT Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: O It. - ft C¢menuc.a. 1 k. Monitoringp�ta� s ss l� ihr Recovery fr. ft. • Injection Well: ftftAqm fer Recha a �G roundwaterRemediation Aquifer ery ��Simi Battier 19.SAND/GRAVEL PACK(if applicable) Storage and Recovery F it tY FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test QStonnwater Drainage ft. ft. Experimental Technology QSubsidence Control ft. ft. Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary) Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,nardnrss;satvrocktype grain size,eta) ft. G ft L'Ay 4.Date Well(s)Completed: . l 6"23 Well ID# ? fr. Hd ft Ot`%1 50 6I\( 521 Sa.Well Location: 6-0 f. 6cd f. Gt 3,-:-:�e. -R+t tra3r�%,.t44-('j:..:tt, t-\t5i r e.S CB It. (k5 fL Ge.h.„' c,' . ' �I:.; _.', Facility/Ownern Name Facility Facility IDil(if applicable) ft. ft ry — -7l a -� 'l(S TT ce. arYM+, Dr 6jrb:u9%)Stn.n�Cit c\tL ft ft �.�'{� J 4 L�L� k Physical Address,City_,,`and Zip ••• Z t k ft. ft. G :� c r•& 21.RE1VIARKS r �1'r)i-^.• t('r°A G � r•.t s�:1•r.,�ti:•. County Parcel Identification No.(PIN) Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lallong is sufficient) 22.Certification: It 'Ce k t t .e / N `77'3' of./. Oi5 - w "3- ) Z -z", 6.Is(are)the well(s) rmanent or ElITemporary Sigetature ofCecdfied ell Contactor Date By signing this form,1 hereby certgi,that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: Oyes or .- No with RSA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a If this is a repair,Jill out known well construction information and explain the nature of the copy of this record has been provided to the well owner. repair under 02I remarks section or on the back of this fonn. 23.Site diagram or additional well details: 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Yon 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: 1/� SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: ` / 5 (ft.) 24a,For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths ifdifferent(example-3@200'and 2Q100) construction to the following: 10.Static water level below top of casing 3 6 (ft) DivisionResources,Information Processing Unit, If seater level is above casing,use"1- of Water 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: (ram (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a Ft r above,also submit one copy of this form within 30 days of completion of well 12.Well construction method: �b�(i.e.auger,rotary,cable,direct push,etc.) construction to the following: FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program, _ 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) �-$ Method of test: GI.1G1,t 1-,''~-- 24c.For Water Supply&Infection Wells: In addition to sending the form to ' Dc , Q the address(es) above, also submit one copy of this form within 30 days of I3b.Disinfection type: C -t /'h Amount: 16 �2 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 1 GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH Division of Environmental Health,Water Quality Unit 400 W.Market St.,Suite 300, Greensboro,NC 274011 Record of Construct Data® Rdpaore or Qb` nd• went of a Address of Well: -J 06 R,t.,,c 4e. Co,r 0^-5 4Dr wSd.;^Avur `LATITUDE 3 36 .c �. Z).14. Well Permit Number: .a `b! - Lori 14Q -ob o ``i LONGITUDE 7 , 37 04',tY3-,, Well Contractor Company: P k,g, -Or;k 1 Completion Date: -3- 1 Total Well Depth: t 5 ft. Well Yield: -Ls- gpm Static Water Level: 3 a ft. Outer Cm'n,g Material: P L Formation Log G Casing Diameter: czs in. Casing Depth: 4.0<e ft. Depth Description From: ft. To: SV ft. F i A y Inner Casing Material: From:_{_ft. To: ( ,, ft. try Sa,;2911 Ste. Casing Diameter: in. Casing Depth: ft. From: f t ft.To: e,Se ft. From: 6k ft.To: 1A5.ft. Grout From: ft. To: ft. Depth Material - Method From: ft. To: ft. From: 0 ft. To: )o ft. C.C,vmewi- coke' From: ft.To: ft. From: ft. To: ft. From: ft.To: ft. From: ft. To: ft. From: ft. To: ft. Water Production Zones Depth: c-a ft. ft. ft. ft. ft. ft. ft. Yield: gpm gpm gpm 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. • Well Contractor: Certification#: L f f 1 -41, Date: 3- « Ci_ w:;. 'e.[Sw� -r•.; •3_".:'..,;T '. "'_n' �r3SK: r'. . ,r_: -;,,.r 4.1,4" = xa:4�i3..-Y=.,_•_'�`_." as: ...___.-._ Record of Pa p Dot&[Illation Pump Installation Company: AvAct, Dr Lt - C-- Completion Date: 3/07H 6,3 • Pump Depth: I ft. Static Water Level: LI 0 ft. Pump Brand: r t oi-.9 L a m 5 Pt 1) 05-P Pump Size and Rating: t/ . hp IV gpm I hereby certify that this pump v,j installe and wellhead completed according to the Guilford County Well Rules in effect on this date an. th t a co l Vie'rd h. been provided to the well owner. ;. >.. t:21,9i - - 3b2-f/ 3 Well Contractor: .-n Certification#: Date:, Revised:January 1,2009 •