HomeMy WebLinkAboutGW1--05748_Well Construction - GW1_20230905 1 i
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WELL CONSTRUCTION.RECORD Ftir Internal Ue.pNLY:..
'Thi,sfonn sail be used fir sinker nuiltipTh wills. . .
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1.Well•CantraCtor ladormatiou: •
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• EliztvAtnitioN Es • - 1 • .
Stefan Smith . FROM• 010 . ' )•DFSERIETION
WA Cott-de:tor Name. ' ft: rt.. 1 1 •
It. If: I I
357 6-A • •
•-,45...OUTEXCASINGVOtadii-ed*AltriUsf OR LINEktif-Oli Medd;
NC Well Contractor Certificuioit Number
nom To • r DIAMETER% THICKNESS' MATERIAL
SAEDACCO - • , it.' • • ' lb;
. ,, , . •
' Company-Name, • 163NNER CASINGOR:TIIBINGlimitherinal ellik11-loilOP'-'-•
FROM TO orAmErEat TMCKNESN MATERIAL
.2..WCICCOILSITRtitIHIPOLIII/III • 0 R. 10 ft.- 1 " 'ill, SCH-40 PVC
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' Litt el nppliciibie.icidi Peiplitz ii,.e;County.Stele,Zariarxe,lefeefigl eJr..) •
- .1.,•...._,:....:' .
• 3.'Welllise-(efirecic well rise)t• . • -47:stitEEN - -• , •
WRIPT SUIlfIly Wel li
. ontist TO - MAMETF;S: SLOT-SIZE TIIICRITSS I MATRRIA I.
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10 : ft, 20 It. 1 '19. .010 SCH-40 PVC
. • ElAgrfelltiltat CiOiliidipliPttbye,, :
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-• 1:1GeOthermal(lleatingiCooling.SupPly) .OResitlential Water&mirky(single) ft• I . it. in
- - • • _,,,,,,,,
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. LlInduStrialiComntercial 1:1Residential WalerSoppl“sirtred) :..yR"';6'.',47.''.•,i'61 . '. "- ' ' — '-- '"- - — • — -— ' '.."' -.
. MAMMAL -EMPLACEMLIT METHOD SL AMOUNT
El Irrigation• . . . . . 'ft. . ft,.• . .,
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,
NoW-Water Supply Well: ft • - -•
• ' ft .
•
Mikitonitoring IDliteoycrj.• - -,
Injection WO: . . . . ft,- • .ft.
PAituiferilecharge CiGiOundwatcr'Reittediation 49AAND/GRAVELPACKIIIMOdieablir- - .-., . ;,--' , _-
- I . , TER AEN .-
- FROM. I MAM. IPLCDNT,--S.t n.iO-n1A0IIOL$LDRgc.aR Tli*I PSalinity Haref
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. • . _ .. . .
•.. . .. , .
. El Aquifer Tesi ' 1:N10m:water Drainage . . . . .
•. . . ft.. • h. '
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Ii8Scperittmotal Tcebrietegy iiSubSidcocc Control •
•:210..'DRILLING11.0Glattiati,id ditioaat Streets-If meieSalii. -
. ClOeotlwm.,11(Closed Leap) ' 11Ttaccf • • .PROM••- TO PMCRITTION(color.luirdnol.acanicti hoe.mlin.'..ioe.cle3
. . OGeothennal(Iealiine(Ci1011ildRetuni) I:Other(explain under.#21 Reloads)
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4."Dati Well(s).completed!."8/1 /23 T Wilt ID#B-15' ' .
'ft. ft. .
-.‘. ..
54,Weld 1.ocatitini: .
•r.L• ' ft. • SEP 0 5 2023
Forest Oaks Circle. K . . . . 0..- . ft.,
,.______: tiforir,.:zatp_., •
ficiliiffhvoerNamo Facility 10 0-appliable)., ' • R. ft:-, --.41e.orccfve--,- .
Dvicveoia-
5324 Liberty Rd., Greensboro, NC; 27406 . ft, . ' • •
010?-}4-AldOss,c.itY--iiiii*if' .• 'IL HERIARES-
Guilford Temporary well for grab sample • .
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County •
. • • Parcel Icieutillculou Nu;(PIN) I
. 5tit LntdC'anillintittitle lit degrccsinilitulleg*OrItk ilr Itocirittil ricgreeli: .22.Certification:, • I) '
Owe!!rreld,mac 14104 ig.mdfliati)
N ‘Y ..t.,-:tii 4. ; 40 wo . 8/24/2023
• bigot!. of Ce_.Gad Well Cciimactor i Date
6.Is WO therwell1(8): 13Perinaitent .or iTeintiorari,'
#2,riining drir jourr,..1 irefelg cettif,u•that the m41(.0619'(Yitlrj corLyinfeted hi act
Oith 15,4 ArAC 02C 791PO or ill NOW 02C.:02647 Well Coottperion Srarulares and sloas a
7.kthis-a irelinIrp an ticiSting ATI* 1:3Vm-• or i131Sto •copkof dikr•iieetird has Iwo provided ro she sveil iiwner.
if dds:h a riperk fill qo bourn well tvmoructlati Informilon and explafn tin'mauve Of the I. .
repair rutirt.02 Fitmarki.1-mien or on rlir baik of shalom .23:$ite.thagrant or additional st.tt details:
Yea 04 use the back of lists page tri-:proYide'adchtional well Site details:or Well
fr.Number of Wells'constructed: 1 • - Construction details; You tour itIsiiattattt idditional Ooges If neeessary.
Far Undid&Irdeeslon ir rum-miser supply Iwelt ONLY with rhesausgeonstruttiou,you eon
suing(Or!e fOrrn. SUBMITTAL INSTUCTIONS ;, • .
• 9.Total Well depth beton-land surface:: 20 • (ft.).•.24a. For AU Walk Submit this font:within 30 days'of completiOn of welt
For nrullipleii.i.ltsllsr all deprlis if clifftrens(exarUple-.3€190'and.2@ MT) construction to the following:
RI.Static water ferd below tap of easing: (11J Illyisitio Of Water liestinrCr..s,InfiwntittiOn processing Unit,.
if trister kyr,Is allure til'aitlg,ire"+" • 1617Nfail.Service(Center,Raleigh,NC 27699-1617 .
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11,Borehole diameter:2•25" • (Im) 24b:For Llifeetion Wells ONLYi In-addition to-sending the fonts to!headdress in
2.101nAre;also submit a..copy of this fonts within-30 days of completion of Well
12.Welleonstruction method:DPT cot Istnictio ti tO.I6 follOWing:- 1,
(i.e.auger,rotary,cable.:direct posit.cre.) v
. • DSloit of Water Resouces,U ndergound itjei!eti Control Pritgram,
FOR WATER SUPPLY WELLS ONLY:" - 1636 Malt Service'Center,Raleigh,NC 276994636
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2.4c.For Water Supply St.injection',Wells:.
13a,Viclt(g)-im) „ ltIctboil of test:
Also submit one'copy of this•fe‘rM Within 30:days of cOmPletion.of•
13b.Disinfection typal Amount: .well 0:mitt:gnat:,to the county fic4Ith department of the.county when,
. constructed.
Form GW4 North Carolina Deirarortmsof Environment amid Natural Resources,Division of Waier Reetu'egs Revised August lit 13