GW1--06648_Well Construction - GW1_20231017

WELL CONSTRUCTION�RECORD`.(GW-1) ' `• ' RNntForm
'For Internal Use Only: ! ..._._.
1.W I Coni oetor lnflirmation:.- • •
- .D-= Id-Seidner.
14:WATER ZONES. . :`.I.
Wolf OnHebtor Naiad - FROM TO. -: .- .DESCUIPflON .
45.4A. -St rr. i 5 M!J'( Vroiilk.ul'el: .
NC ell CoatraetorCerNtiinifoaNur. D•: ;
Aq a Drill, Inc.. R dw
OUTER CASINGObrmalsed_wens)ORLINEROat) cable) _ _: •.
- FROM • _- .TO: • - • DIAMETER. . ' THICKNESS`. . MATERIAL •
Camp:',YName .. • . .0: rt."Sri. ff:,' , 1e.:. . . :
2;:W u eoastraetion Permit#: a �7 ).N
3'-t -:4W1t••Oo4'i 7- -:1AINNE
FROM'
•R --TO.: OR• IN R -. .. CKtoa OptEs ) :-MATERIAL '- List a applicable welt,constrtrctionpemrite.(i a_ IC;Counq•,State,Yatimice,etc.) - ' ft. : . - ft: . :In.'
3:W R Use(check well use):,
- Wale Su - .. : : � � � • •� � � - - _ � � ..
pply A cultural - 'DIAMETER' SLOTSIZE •.'THICKNESS '.,MATERIAL - : •
e ge4liv iiubli.o:' FROM TO .
• ft. ff: :io;
Ge. 1 urinal(Heating/Cooling'Supply)' ' Residential Water Supply(ale) ' • -
.. Ind <tiiaUCommetcial" _ _ -� : ft.
fn.., . . . . • '
, ' DResideatial Water Supply(shared). 1e.GROUT • . • •. ' :• ••• • • • •"
Non-. Ott"t FROM:. _ To MATERIAL EMPLACEMENT METHOD&AMOUNT
SaPPb!well -. . , . . . - ..017. - -
: :: 1I:. fr.' Ce Qn�:. : li Tr
tu(',ttililri uPl
. . .IgjectIoa 61
' AqulferRecher e • �Grotindw.atr Remediation ; .. .tb.
.-
• • _.-
Aquifer Stu age and Re overt' .. g Battiar: ' ' • • 19 SAND/GRAVEL PACK(Ihtntditable)
- • FROM _; •TO . •MATERKAL' - -ESTPLACEMENTMKTROD '.A er Test'. .
�3lomtwater Drainage. - >w• ft.. � - - •-- -
Exp imentel Technology. " Subsidence Control • fL: . ' : :fi'
ermal(Closed Loop) Tracbr : . .• .
. . • D ... : . : • :2e.DRILLING IA)G(attach oddtaoul sheets tract:sstiri). ' • .
ermal(Heating/CocliagRetam) .•f Other(nankin under#21 Remesiss) : •FROM . . TO • : 9
ESCw77o7"
ester.ttudne'!E' mehtyps,eraln Ike..de.)' • •4.•Dat'Wells)Completed:.9..4 .E?3 Well ID# ' :• • l fie :V ' -R.. .el,
11
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• .� .. .
SaW location:. .• .. R. _ • .•
'r). . d) r.'N.: : . . . . • . . . ' . . . . .• • . . . .• . . .. ..R. 444 ft �t1L ,-ett�R(litP.. • . . .
••FacilityOsynerName. p'• : . . : a• FacilitylDs#,(Ifapplicable)' : : • R;; . 'iG - • . :
.'35 0. J .61A. h . C•�y �`Yd��Srlif1`a) .. . R'.. '. , " f• • '
Physics Address;Cityc and Zip IL . -' Pt: --7• - • • r .
(/1�n�. /. 1 p
•
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•
. COUney .• • . . : .. FaicelIdcatifcalmiNo;(Pa) OCT... • • . . . - • - 'OCT a- •�• .?023 ' • • : .
56.La 1 lode and longitude in degrees/migateitsewads or decimal degrees:. •
. Owen 1d,one tit/long Is sufficient) . . • .
22.Certification• I ns� r :r r• 1_;F
5(k:V r ' N. '•8'6e)1. 3f`e..04. • W':' .. :' G. Y
rfoLk •�•Q ' a3...
6.Isla =)the weil(s) Permanent •iti-.E3Temporary sigua, ofceeifled waltcow:actor 1. .. • Da
7.Ie.th s a repair to an exfatin wen:.. Yes'.of. - ' • • -BY ata this form;!heirbY_surlily iliac the Suet/(�.was-(were)constructed in accordance
C �. n . •: ". . willsISANCdCO2C 0100'orISANCACO20.0200.Wet/Construction StandardaandMaj .
(/'IN,is repair.Jil1 outlnown ivel1 construitlon is omrmion card piplatn the naive gfthe" OPY.019h1s rBroriI hasbeen provided to the.iiell owner:: .repair der CI ioman�,section Cron the bdckofthis jbmc.. : . ' •• . . . . : ' • .
' ". 23.Site diagram or additional well details • • • • •• • • • • _
••• :8.For 1•eoprobe/DPTbr.Cioaed-Loop t�cotheiinal Weis having the same.':':'''You may use the back of this page to provide.addititnral.well site details or well;.- -
. coaatru too,only 1 GV1►1 is needed. Indicate TOTAL NUMBER'ofwells ',-,'• ':consht:ctioa details•.Yea may alas attach eddidoaal pages rf net1easary. -' •.
drilled . . .. . . .
• • : •.•. •: - .• • $UBMITTAL INSTRUCI•IO1VS L • - '
9.Tote well depth below land surface 4(n5' •
Form , ;leiveP;ldstalldepths('d/erent(example.3(g200'and2@100y ( '):: •ior:A11.Welise this•form:within 30 days'of completion of.well.'
constinctica to he£ollow•uig:
10.fit# ewater level below top ofeasing; .• CO. ' . •
IJtivater elfsabovecashi ecse+^ . : ( ) - . Division of WaterResoarcea;Information'ProcessingUnit,
. - • 1617 Mail`Service Center,Raleigh,NC.27699-1617. • '
11.;Bur�hole iifameter: - '
�a •'24b.1?orlidection We In adthtion to.Sending the foraM'to the address in 24a -
• " ' • -" ' • • above,'also submit ones•
.12.W• kunetracnon.methodi• I�ettA Q,I` copy of thin foam within 3• • days•o•• completion• •well
• (I.e.auge{,rotaiy.cable,direct Push.eta).. "• _ • • :constntctioa.to the fbllowing; • • .
ivisi FOR WATER SUPPLY WELLS ONLY: � •
.
' -D on of Water Resources,Underground Igiectloa Control program,
]636•Mall 3endce Center,Rnle h,NC 27699.163E
13a.Yield(gpin) 1 . ..
..Method of test (0k(1+"T:ethp. . .211e.For Water Suunly&.Inlet Son Wells:In addition to sending the,tbrat to - . •
•
. the-addrsss(es)above. also'sobmitt one.copy of this; Onif within'30 days`:of• : • - '.
' 13b.Didnfeetion type: 'vu r ri tM• !e1 ': Amount: : (G�c%+y. .: .. completion:of well.contraction•to the county health department of the county.
.�;whcnecoosttuoted. . : - i -
-• `Fenn GW 1 - - . . . North Carolina Depani ont.of Environmental ••. . . . . Quality-Dlvisiotiof Water esoaeces• Revised 2:22 2e16

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GUILFORD COUNTY DEPARTMENT OP PUBLIC HEALTH. . :
Division ofBnvironmental Health,Water Quality,Unit
400tW.•MarketSt:,Suite 300; Greensboro,-NC 27401• •
ecor :of Construction, Repair, or Abandonment of a Well
dress of Well: 5. OI�. )Csikx4e. CA.;1 S4c1p1.esjol .MC. 7357 : LATITUDE:31L. : t.,.!. ()
lI Permit Number. 83 O'7 -tjA/14 3 '7 LONGITUDE Co
We I'Contractor Company r ' ui toe. : . . .
� .e,;. . . Completion Date:
Total Weil Depth:- 1 66 ft.. ,Well.Yield: 15' ,gpm Static Water Level: 5 ft.
Ou • 'Casin Material: i Foranation Log
Cas ng Diameter: - in; .Casing Depth 'P : ft.: ; Depth;e
P ' Description
From O ft.To:_{eft. Catty
Inn•r Casing Material:. : . . From ,20 ft:To:..I ft. !an
Cas ng Diameter: Saki
in. Casing Depth : :ft.- -From: &5 ft..To: ,fie, ft.
From: Xo .ft To: LI(A.ft. 'tire.(veinqe.
, . . . - . . Grout
.From. it To: ft.
Depth : . : . Material Method From: ft.To: ft:
Pro O . :ft To:.07 .ft, (pMPn4 ?e .pi.,i:tbrrti mom: . ' ft:To:_ft.
Fro s:.._^ft.To: ft, ft:.To: ft,
Fro 'ft To:._ - : ` _ Rem: ft
o ; � From:
. .ft:To:. ft.
Water Production Zones
pep,i 4116 ft:: : :: ft. : ft.. _ :: : ft,
gpm.
m . .
gpm,. gpm. . gpm. ::.
Met od of Repair
. . Me . od of Abandonment:
I he :by certify that this-well.was constructed,. .repaired,:or abandoned according.to the Guilford County Well
Rut-:in effect oirtins date and'thata copy of this record has been provided to the well owner. :
Well ontractor r)criod �j.o i� r, Certification#: 4544. A . Date: .
:Record of Pump Installation
Pump Installation Company 'tr;.'lf. , —t..!"1C_ m : - . •
Completion Date: I sIaL-3
: .Pump Depth' I l^J ft 'Static Water t evel: 44 ft,
Pump Brand: •F101.01, .1. m'71_Pipscr7 . 3
-
. . . ump Size and:Rating:' .
� hp: /®- gpm
_ . I hare y certify that tbis.pump:was installed:and wellhead completed•accordingto.the Guilford'County.Well
Rules. n:effect on this date and that a•co f
. PY of this record has been provided to the Well:owner:.
Well 4 ontractor• cam` 9� ' Date:.
�� �c%' '- � Certification-#::��^7'7
Revised:Januery.1,2009. ::