GW1--07403_Well Construction - GW1_20231117

• • -____•_,
ELL CONSTRUCTION RECORD(GW-1) • For Internal Use Only: •
I:We Contractor Information: •
:Chris King' - . :
14:WATER•ZONES '
Well C ntiactor Name ' • : .. FROM TO • DESCRIPTION
208 -A /'� ft: {t, !Z .
. ft.. • 1 ft. : �
:
' NC We I Cotitro*r Certification Number.
•15:OUTER CASING(for:mald-eased wells)OR LINER(Ifup'11ca61e)- _
:Aqua Drill;Inc. • 'FROM . ' TO-" • .DIAMETER THICKNESS. ' [I DATERIAL"
Comps Iy Name• .. '. . •0:,ft.•I 50 ft. / in: I'pi if A� .
IC�f�1 ISIDR'2) r
16:INNER CASING TUBING(geothermal dosed-loop)• _
2.Wel Construction.Permit# � •6? FROM• TO" DIAMETER THICKNESS, MATERIAL".List all 1 ppliraide azU col(s1r1(ctinn permits(i.e.U/C Cot(nry;State,Variance.-etc:) - _ • ft., fL in '
1 Wel .Use(check%yell use): ft, ft. , in: . : :
Water Sttpply•We11 - : • 17 SCREEN
FROM ROM TO DIAMETER ' .SLOTSIZE' . .THICKNESS ,•MATERIAL.
Geotl'altars! �MunicipaVPoblic crmal(Heating/Cooling Supply) argssidentiaiWater Supply(single)
Indus rial/Conunercitil :0Residenual Water Supply.(shared)
•
It iga ion
fr ft in"
. -. • t
METHOD Io
FROM ROUT:
Non-ti�' ter.Supply Well
TO ' � MATERIAL� �EMPLACEMENT ME D fi•AM1 UNT
ft ft. ;_
. Monitoring .. . �((�- � loll +. T2ijc •.'
i ��Rccovcry ft. ft.
'Injection Well: - -
Aquitr Recharge •.. Groundwater Remediation • :
Agttit.r Storage and Recove • 19 SAND/GRAVEL PACK(ifappllcable)• 'ry riSalinity Barrier• FROM ' .To •"'_. MATERIAL: E\IP1.ACEaIENTMETHOD
A9tiifor ee Stonnwatenl)rainage• ft.' ft,
• lixper menial TechnologySubsidence Control. •ft. ft. .
'Geoth n1:al(Closed Loop)' }Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(HeatinglCooling Return '
l •rOther(explain under#2I.Rt uriarks) FROM TO -DESCRIPTION(color,hardness,so.Wroc6 type,Aram SW,ete.) .
. . • 0 . ft - 9 ft. T�cd c f 6.1. •
4.Date ell(s)Completedi'rI?'/�`2 3.Well ID# S ft. G�
,� •I 3 .- � � . iapr�: roc
Sa:Well Location: :'.ft. .ft.
• ft. ft.
• •
Faciin iok.zzNanic • ' . •Facilit3%1D::(ifapplicable) ..ft• I ft.'
&S.: K !_a c.rzc Fa26 . 17.1tAStg�. • . ft :ft. ; .
Physical F ddrcss,City,and Zip. ft ft ' • • • • • 7
•
zl.REMARKS .
" . County • • ParcclhicntificationNo:(PIN) • hit i ' 7 t'S;"i '
J
Sb,Latit de,and'lon %lode in d d g egreestininutes/seconds or decimal degrees::- • .• "
11
• (ifwcil Ia.d.One lat,'iong is sufficient)
22,Certification: - •
•
•
•
. ' . ' .
/5 // ii do -3'-
6.Is(are)the wells ,permanent or,L Temporary Signature ofCentfied Well Co 'actor Date"
• Br signing lhic finer,1 hereby eertifr that the ut/1(s)ucls(%rare)enn 1,,a led in aecor dance.
7.is this t repair to art existing Well: . Yes or� with 154 Il GAC 02C.0100,nr 15A NCAC 02C.0300 hell Conshviclinn Standards and that a
If this.is e,c,?air,RI n111%'lean1 Iva ratici 7r(•11n11/rl jn aiaB(ln and itylain the Bailee of the 1.1'(f i/iis re(•nrd has-been r osudcd hi the ire/l ouster.-r(yrair and r=21 renrarkc seet)ari or on ilea hark(fdfic j{r7n:
•
r
23:Site diagram or additional well details:•
S:For Gcoprobe/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 •
constructi» only 1-GW-1 is needed. Indicate TOTAL NUMBER'of wells construction details. You may.also attach additional pages.ifn ry• ececsa .'
drilled: .
SUBMITTAL INSTRUCTIONS
9.Total N ell depth below land surface: t
Foriridiipl heirslist all depthsiJ'dyerent(ecamplc-3@200'and 3((s/00' . ( ) con24a For.All the following:it this form Within 30 days et-completion of well •
construction to the ' •
• 10 Static water level below tog.of casing: �Q • (ft.). Division of Water Resources
Ift,ater lei.i is above casing,use•:+' ,Inforirtadon Processing•Unit, •
1617 Mall Service Center,Raleigh,NC27699-1617 •
-
11:)Dorehsle diameter:- .. (in;) -• - 24b,For Injection Wells: In addition to sending tire form to the address.in 24a
12.Well construction method:. (� /Zj I I •` above,also submit one copy of this:form within 30 days of completion of well l
(i.e.auger,rotary,cable,direct'push,etc._) ' " construction to the following i
FOR Wig ER SUPPLY WELLS ONLY: • Division of.Water Resources,Underground Injection_Control Program,
1636 Mail Center,Raleigh;NC 27699-1636
13a.Yield(gi?nt) Method of test:. Sc(i � •
•
24c.For Water Supply ez Iniection Wells: In addition to sending the form to
the address(es). above, also submit I one copy of this form within 30 days of
' .I3b.Disinfection type: •14T W Amount: 16 -(')' completion of well construction to the county health department of the county
- . where constructed. +
Form(3W-i North Carolina Department of F..nvirnnnwn(ni n,...t:..,_r�:..:..:.,--.•.,,-.__... I

GUILFORD COUNTY DEPARTMENT:OF PUBLIC HEALTH '
Di
vision of Environmental Health,'Water Quality Unit
400 W.Market St:,.Suite 300, .Greensboro,NC 27401 .• • '
•
Record of Construction; Repair,.or'Abandonment of a Well :.
Ad ress of Well:��,5cl g, /zd:
. W ]I Permit Number � TITUDE
3
Wel Contractor Company: Aqua Drill, Inc. Co �• l
_ • ' •: • : -._ • . imp etion-Date /1-!/ ,2 3.
Total Well Depth: �
p 1'�,�: ft..' : Well:Yield. 3 ra . gpm. : .Static Water Level: . a ft.
Out r Casing: 1 Material Si)lt_A:I d i
Jac�t C. Formation Log
Casing Diameter ly in. . Casing Depth ,5-O : ft, . Depth
P �Descriptionc
• Inner CasingFrom ft. To � ft
�•
•:Material . . © � • � ���Y
Casing Diameter 'in. CasingDepth: -.. -. •� - From 3: ft.To:�l�$•ft. ; Ss4tu� :re-cjC
p • .' .From9S ft.To:i>Ss ft. Bli e _CyLig .
From ft. To ft.
Grout • From ft. To:.
DepthMaterial . : Method From . . ' ft. To ft. .
From'Q : ft.To o. ft. :'
From : . :.. . . ..
From
ft:To: ft. ft.To ft
�. . From
From :� ft.To � ft
ft..To __ .. :From: . ft.To:
Water Production Zones
Depths 'grafi. ft
'Yield. gPm gpm � . ft. • ft. ft. ;' ft. ,ft.
gpm gpm gPm J. gpm • gpm •
Method of Repair
Method of Abandonment: '
I hereb, certify that this well was constructed,repaired,or abandoned according toy the Guilford County Well :
Rules ih effect on this-dat a that copy of this record has been provided to the well: owner;
Well Cb hris irtg
ntractor: - Certification it: 2080-A.
Da
•
Record of Pump Installation .
Pump staiiation Company: #9 i'- 1Q. ;�eL,�I.L .iv' '
Completion Date: /d f
Pump Depth: ./DO_ _ ft. Static Water level: /O- .1 , . ft.
Pump Band ' A3 4 /O 7. . . ' , /
. Pump Size:andRatin : � h d d
g ��' p• gpm
I hereb certifythat this ' ' . . .'3 pump was installed and wellhead completed according to the Guilford County Well
Rules inn effect on this date and that a copy of this record has beenprovided the w •to the well owner.
Well Contractor: / / .
(p
�s'�.: -. Certification#� ?I2' e .Date: f l(o �
Revised:January 1,2009