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Home My WebLink AboutGW1--07400_Well Construction - GW1_20231117 • • .WELL:cCONST i'UCTION Il CORD(GW=1) : • • For Internal Use Only:" { I.WelContractor Information: 14 WATER ZONES l .Well Co tractoi Name .• .• . li FRO 1 •"TO 'DESCRIPTION 2080-A 6: ft 66 ft. �6 ; c t r', P- . . . :.• NC:Weil Coniructor Cettifitatimi Number '• tt. ft. '15.OUTER CASING(for multi-cased,wells)OR LINER(if ap licable). Aqua Drill,"Inc, • • FROM...--' ..TO ' ' :DIAMETER THICKNESS ' 'MATERiAL . Compan Name' . • '. . - - 0• f' t�r .ft: / /,4 in AA n • 16.INNER CASING.OR TUBING(aeothermal-closed-loo �.- t•i/r� . �//� C -FROM, p)•- 2:Well Consti uchon Permit#77t� �� R. � �TO`. ' ' DIMiETER'' -.THICKNESS MATERIAL . . , . List a/i citiplicohle well conttruction petmns(i e.'UIC Counts State;Vat iance,'etc.) /� • ft.• " ft ; " in. . 3,:Well Use(checkwell use): .• . • " • • : •lyater apply Well: • .•• . :17:SCREEN.. . . Agric inns! . : FROM •To' DIAMETER SLOT SIZE THICKNESS. 1.-MATE...RIAL ' . .• unicipal/Public .. M Geot.i mial(He,.tin /Cooling Su l Residential Water Supply.(single)• I ^ ... .ff ft.. in. g 5. Pp Y) . •. . ft:; in.' Indust ialiCommer"cial • - QRcsidcnnal Water Supply(shared):.' ' Inia.t or.' . --' •- .. _ .MATERIAL • - EMPLACEMENT METHOD&AMOUNT 1s.GRo Non-VPi to Su)iph'Well: t ft. it, FRO\ TO�� (3 Montt ring'. '. I�''1Recovc �+. v 6vi Pyid-ti- /Z t1 c.1� . dnjecho Welt: , - Aquif r Recharge . t_ ft ff.. • Groundwater Remediation - _ � • , • t gRi r Storage and Recovery• Salinity Barrier • 19.:SAND/GRAVELRACK(if applicable)- , •• • 'FROM.. -TO :MATERIAL• .. F,�IPLACF.t1fENT METHOD " Aq ii r Ts: • : DStorinw.ater Drainage ft. : •: Expert iiental Technology . - [jSubsidence Control- - " : • 'ff.. •.:• "at. ' • . • • • (Geotiii.rntal(Closed Loop) •EtTracer-" • • ' .: 20 DRiLLINGLOG(attachadditionalsheetsifnecessar r) - - J Geotherina1(Heating/Cooling Retnm)." .EIOttier(exp.lain_under#21 Remarks) FRO I- _ 1.TO`. - DESCRIPTION(color;hardness:soiifrack tspe:gram size,etc.)' • ft ' L�• S:Date`Vell(s)Completed:t(�/d �. Well ID#Fai3 1- 2.O ft • "ft: ' •Sa.Wen 1.cc2ticini•• : • • . . : • 9d ff. ./g`s ff. 13/t,c . . Facibi}.n vnc 'at c •- .: ft. 1 T. f Faciliry•:IUO'(if ap}ilicablc) 4 � i // � . ft. s �_> .�, 5-66 t9 • •- e2� m {I° s�rJ a— ft ft : : NOV-N O V 1: s 2023. . Piiysic•tl.i ddn>s.City,pnd Zip ft ff i . . � �TpCL�erX•�,t G � �j-e,lL$ a1i� ' _ . 217REMARICS .. • u i , Parcel Identification No.(PIN). ' is . Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees ' c • , (ifw0 fc d.one lt/lg issufficicn)' ' . •• 12.Certificati . . . 6.1s(are)�the well(s)♦ ermanent or OTemporary Signatutc ofCemfic Well Con pate. • By sitting this Rini,1 herchr:ceth•that the nr.Z/(s)was(uuel rrinstraeted in aceortlance 7.Is this repair to an•existing well:, QYes or ZNo. • a.u rth 154 NCAC 0?C.0100 tic ISA NCAC I)1C.01Q0 Well Conslrpciinn Sianda,YG anti'Girt .If ibis is a 4cpgir,fill out knon,,itch!constrattlon It jirntaiinn'mut espla/n the nature nftGe it+/il oftl+%r ictanlFiat hccn prtir deal/o 1/ie uel/airner:: . repair ii al4-t 21.ri.niarks sciaion or nn the hack(Phis fium.: - . 23 Site• 'diagram or additional well details: B.*For Goprobe/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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary: drilled '� •i SUBMITTAL INSTRUCTIONS" 9.Total 1' ell depth belotp land surface . - - • • • ft.) Fornitrltip !yells list all depths if different(eranrple 3(r�100'pied 2(ta100:) ( •24a. For.All Wells. Submit •this form •w•ithin 30 days of.completion of,well. 'construction to the following: 1• ' ' ' 10,Static water level below top of casing 3o -(ft,) . Ifwater.!ei•r!is abai a ctising,use +^ � Division of Water Resources,information Processing Unit, • 1617 Mail Service Center,Raleigh,A'C 27699 1617 11.Bor thole:diameter: (in) 24b.For Iniection Wells: In addition to sending the form to the address in 24a 12."%Vell onstruction method: /47 above,,also submit one copy'of this'font'within 30 days of completion of well'" ( i2 I l'. construction to the following:. '(i.e.auger,11omry,cable,direct push.etc.) g: • • Division of Water Resources,Underground.Injection Control Program, FOR WATER SUPPLY WELLS.ONLY: . ' ' • I . . •. 163fi Mail Service Center,Raleigh;NC 2769'9-1636. I I. 13a.Yield(gum) •0 . . .• Vlethodoftest: •`�t7I�h - •24c.For Water Supply&Inlection.Wells: 'In addition to sending the.form to . / • • the address(Cs) above, also-submit lone copy of this form within 30 days of 13b.Disinfection type:_Lf/.N. •' .Amount:'/6 O`G . completion of well construction to the;county.health department of the.county • •- where constructed. I. Forth GVV-1 North Carolina•Department of Enviromnental Quality Division of Water Resources • -. Revised 2-22-9(116, i i GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH : .. . Division of Environmental Health,Water Quality Jnit 400 V�:Market.. . . St.,Suite 300,. Greensboro;NC 27401: Record of Construction, Repair; or-Abandonment of a:Well Ad•ress of W\e11 (4D 72S , 9)ip q . LATITUDE 3 • We 1 Permit Number: 2 3: ^(� ? l.Jrvj2- 03`l . � • .. . . : � NQ17l1DE . Well Contractor Company : Aqua Drill; Inc: :-'�Completion Date // /o "a 3 Total Well De th I�.S : ft: O :- P � � -� Well.Yield•:� m � :.Static Water Level. ft. • Outer:Casing Material 3 �.1 �1 u% C - . • / 2 - � : . � Form. atron Log Casing Diameter:fa A f in: ,Casing Depth::- .-I ft. Depth � Description :From O. ft. 'Tine; ;ft. Ord r i p Inner Casing: E Material = To;- � � � From (n . �ft. ft: 5is Aid Casing Diameter in:. Casing Depth ft. From: fl::To� - S-ft: • l� K G rout,. . : • rom: ft.:To� ft.• From . : • ft.To . ft•... . Depth. Material Method . From: r� it TO: From: ft::To 26 .ft, Cl'�n n n�-I -t - - � r�lLctcic: From .. ft.To � � ft. . � . . •-.. ..From1- ft.To ft• - • From• ft. To: i.. ft. .� Froma : : ft.To• ft. From: : ft. To. H. .ft;.• . Wat er Production Zones Depth 4 eft::.. . � : .ft. .� : ft. d. � �-gpm . . m. � - .. gP gpm gpm . gpm Method of Repair - . : Method ofAbandi n uent • : I;hereby certify that this well was constructed,repaired;or abandoned according to the Guilford County Well Rules ir effect on•this e.and th a copy of this record has been provided to the well owner: • • . .,Chris Kfn Well Contractor: .9Certification*: 2080-A . Date:f� /v 3 .. :Record of Pump. installation Pump Installation Company:ittitts9 At 4 it 1 Completion Date ` 3. . • • Pump.Depth: 100... . ft.:Static Water Level:: 3Q ft. Rating; yPump Brand: rl 1/�5.��' Pump 52ze:and� . hp L'�0 : gpm I hereby certify that this pump was installed and wellhead completed according to the Guilford Count . Rules i effect on this date and that a copy y Well of this.i:ecord has been provided to the well owner Well C Certification#: t 2 2 C Date: Revised:January 1,2009