GW1--00318_Well Construction - GW1_20240112

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--Print:Fora, .,•,, 1. .
WELL CONSTRUCTION RECORD(GW41 For Internal US4 Only: ,
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1.Well Contractor Information: , .
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Gary Thompson _ . IC WATER ZONES-• ...:' :- ; ,- - , 1-- --- • , • : •:._-,., ,
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FROM TO , Dzscruirrtow
Well Contractor Name
4418-A- • .11:6ft• . 30-&-ft• cm„Illsr- I
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ft. ft. " L
I.
NC Well Contractor Certification Number
15.-OUTER CASING(for nnall-eued wells)OR LINER(If sin - le)
Aqua.Drill, Inc ' FROM TO DIAMETER -THICKNESS. MATERIAL
C> ft• -51"ft.Corn pany Name G. I.,in. .$.1)
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16.INNER CASING OR TUBING nreethermal dosed-loeo),, -..:-.:_--- . .•. -,...- .
2.Well Construction Perndt It:,n:3O6P4,-fhii4rt-la01-44 FROM TO DIAMETER _ THICKNESS MATERIAL '
List all applicable well construction permits 1 VIC,Counry,State,Variance,etc.) ft. ft. i 1°.
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- 3.Well Use(check welinse): . : -ft. IL I in.
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Water Supply Wen:
FROM TO DIAMETER SLAYS`SIZE THICKNESS MATERIAL
Agricultural DIVIopallPublic . ft.- . ft.
In
Geothermal(Heating/Cooling Supply) rig‘sidential Watir Supply(single)
Industrial/Commercial O
I- Residential Water Supply(shared) _l$ OUT
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in.. .
...-‘, -,.... . . - • .
Irriaation . FROM To MATERIAL
ENIPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. iL
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, . 0Mciiiitoring Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Geotherfital(Closed Loop), Tracer
Geothermal(Hcating(CoOling Return) flOthet(explain under#2I Remarks)
19.SAND/GRAVEL'PAcK Of applicable): . '. ,---.--
I . _ • '.. .,- : s.7.--, '
. • FROM TO MATERIAL EMPLACEMENT METHOD
ft. tt.
IL • ft.
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20.DRILLING LOG batch additiomd sheets if necessarV)'•:. . ., ...- . ,... •:, .-'
FRODM, ft. TOs.. DESCRIPTION(color,timidness,solUreck type,vela Wm,
ClikNi
r% 1
4.Date Well(s)Completed: 11:1-1 ".`01 Well IN rt
S' . SI) ft.- Art.?
SA.Weil Location: _V.R. . ..1-,,r ft'
6.1I.t 5 er ist9d).k_ .
. I,
s-6-ft, sot Y.ft.
Facility/Owner Name Facility ID#(if applicable) rt. ft., 11,
ft. ft.
C 4:11.1 DL.Oi OA t !......1160.t•-/IN il .-j,`,/.1..17-i 1 i..,,*.-_) .,....."-‘7":. lir.:p...,„„
Physical Address,City,and Zip
I . ft. ft. .t L.,-4.-4,L a V e.....i....1
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. Gk..) Cet e•ISI, .21:REMARKS ,...,---..-. . - - •- 1.-- JAN 1-"2-2024:
County Parcel Identification No.'(PIN) i 0. ,
kinfr.37(41-4izn iens lei
,Sb.Laritude and longitude in degrees/minutes/seconds or decimal degrees: -
Prr,
:.:, I,. 1,riovt.riosco ()
.A..Xe
ze
(ifwell.field;one lat/long is sufficient) 22.Certification: : .-
.N 7V 33 G. 5-34€e.0 w
be_ 1
Lerhyvi..6--- l' i'•••• Li'..1.4 . ,
signa-in&arri ed WeIl Contractor 1 'Date • .
6.h(are)the Well(s)6Krmanent or °Temporary " . .
7.Is this a repair to an existing well: E3Yes or gi:r: By stnind this fonn,-I hereby certifif that'the well(s)was(isere)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction:standards and that a
If thisls ii reit:It:Pont blown well construction information and explain the nature of the copy of this record hos been Prorlded in the well owner.
repair under#21 reptant,'sectlan or on the back ofthIsform.
. 23.Site diagram or additional well details:
S.Frit Geoprobe/DPT or Closed-Loop Geothermal Wells hiving the same You may use the back of this page to provide additiOnal well site details or well •
conStruction,only"1 OW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
4.-. drilled:_ .
_-.-.,.. . SUBMITTAL INSTRUCITONS
9.TOtalwell depth below-land surface
(ft) 24a.:For All Wells: Submit this('arm within 30 days of completion of well
For nutitipkivellsilst all depths If different(example-3@200?and 2(41100)' construction to the following:
I . '10.Siatiewater level below top of casing: • 45- (IL) Division of Water Itesourees,Information Processing Unit, . .
ruuter level is aboVe casing use"I-" 16A7 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)- . I '
24b.por Inieerion.Wells; In addition Ito sending the form to.the address in 24a
.-;:... •• above,also submit.one copy of thisi fonn within 30 days of completion of well
12:Well construction method: /Wilt:,1 pel e- construction to the following• :
(i.e.auger,rotary,cable,direct push,etc.) I .
Division Of Water Resources,Underground Injection Control•Program,
FOR WATER SUPPLY WELLS ONLY: I 1636 Moil Service Center,lbdeigh,NC 276994636-
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13a.yield(gpm) t 11- Ivierbod drat: dAlki"4 44"v't, 24c.for Witter Saintly&Infection wens: In addition to-sending the form to
the address(es) above, also submit-Ione copy of this foneifithiii 30 days of
•--, 13b.Disinfection typo 1:4,1141D t. Amount: i 4 /2.... completion of well construction to the county health department of the county '
where consttucted.
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Perin OW4 North Carolina Departnient of Environmental Qtiality-Division of Water.Resources RiMiscd 2-22-2016
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• GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH'
Division of Environmental Health,Water Quality Unit
400 W.Market St.,Suite 300, Greensboro,NC 27401,
of Construction Repair ©IF Abandon:00ot Of a Wen P
Address of Well: Gs—1'7 Dizs4(1 ht.°. b4,14y 2119 5/ LarrpoE 35Z
Well Permit Number: 2.3 - -4.31/R) 14 - 36 6 Lowarruim 79° 3-'5 s .s'4•`,
Well Contractor Company: AO 4 R•.1 k .. .'L Completion Date:
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Total Well Depth: LI 111' ft. Well Yield: I '2- gpm Static Water Level: 15 ft.
Outer Casing Material: .111- P Y
Formation Log
Casing Diameter: 6,/j5- in. Casing Depth: SS' ft. Depth Description
From: 0 ft.To: C ft. ci
Inner Casing Material: From: s- ft.To: 5% ft.
Casing Diameter: in. Casing Depth: ft. From: cp ft.To:, tr ft. cora,-.1i-c
From: rs-ft.To:147 ft. Car
Grout From: ft. To: ft.
Depth Material Method From: ft.To: ft
From: 0 ft. To: -7..V ft. cirn.g.t puo.,c) From: ft.To: ft.
From: ft.To: ft. From: ft.To: ft.
From: ft.To: ft. From: ft. To: ft.
Water Production ZORROS
Depth: S6 21 ft. ft. ft. ft. ft. ft. ft.
Yield: 2tipm gpm gpm gpm gpm gpm
Method of Repair:
Method of Abandonment: _ •
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• 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/)1 JV-A, Date: - t-1=4,
S •L • ••••• •sr...
Record of Pump lEnstalbyden
Pump Installation Company: Completion Date:
• Pump Depth: ft.. Static Water Level: 1 ft.
Pump Brand: Pump Size and Rating: hp gpm
. I hereby certify that this pump was installed and wellhead completed 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#: ' Date:
Raulaad:Januaty 1,2009