GW1--00935_Well Construction - GW1_20240209

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WELL.CONSTRUCTION•RECORD.(GW-I)- . . . . .
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1.Well Contractor InformadOn;
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• ...Chris King . -
. • •14.WATER ZONES • ' : •„; - - . : . .
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WilICOntractor Name .
PROM - •TO. • DESCRIPTION • ' •
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•2080-A• ..2/5177,02/6-.ft±. .16'. .61 Pm
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NC Well Contractor Certification Number
" • ' ' '• IS;OUTER CASING(far Multi-cued wells)OR LINER(If applicable) • .-. •Aqua-Drill,Inc: FROM'• : .TO ' • DIAMETER • 'THICICNESS.- 1 MATERIAL
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Company Name• • •
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FRI6.0IMNNER CASTOING OR TUBINGDIERT/1th'el:inalTsici°Ised.4°11)-. •.MAiERIAL
.2.Well Construction Perrnit th..2g_ 0.57-76-iirvalZi-1)02bi '
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List all applicable I'Mli eons/me/Ian permits.(te,'UIC,'Coufity;Slate,Varlahce,etc). '-• 'ft•' . ' ' .ft; ..' . ' !in' • .... -. . .
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.:3:Well Use(check well use):. ft In.
- - ' - .17.SCREEN . • - -
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• ' Water,Supp.ly Well .
- FROM' TO . - :DIAMETER: •SLOT SIZE .THICKNESS • MATERIAL . .
. . . Agricultural . .•Otylunicipal/Publia.
ft ft In
-. Geothermal(Heating/Cooling Supply) •egraesideptial Water Supply(single) -. - -ft.- • •ft.• •In.. 1.:* : ' ' : , . •
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Industrial/Commercial ,'DResidential Water Supply(shared) 18.GROUT • - . • . . . , . . . . . . • - '
• Irriaation•. . . . . . . . , . • :. - - . . . . - , • FROM • •TO . MATERIAL. • E5IPLACEMENT METHOD&AMOUNT'
Non Water Supply Well:: . • ' .:-02"ft... ft'..'dein' CAt . ..-TiZUCg ' . ..
.• Monitoring. . - Recovery ft. ft
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• injection Well: • , :
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ft ft.
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Aquifer Recharge. • OGroundWater Remcchatioit •
• . . .. . • 19.SAND/GRAVEL PACK(If applicable) • - . - -• .. . • .
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Aquifer Storage and Recovery• .OsalinitYBarrier ' . : . •FROM . TO • MATERIAL . .. 'EMPLACEMENT METHOD ••
• .Aquifer Test • '''DStonnwater Drainage ft ft.
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Experimental Technology . 211.Subsidence Control . ft ft. . . . .• . . .• . Gebtherinal(Closed Loop) - : 111 Tracer. ' • . 20.DRILLING-LOG(athtelfaddltionalaheeta If necessary) • . .' .• ..
• Geothermal(Heating/Cooling
Retun) 10ther(explainonder#21 Remarks) FR.°" ' 7ti o.
adT ION..(coloro haness.s.
olUrek type,.grts ales.etc.)
4,Date Well(s)Coipleted:/ 25 ,Y Well 1E# L4k1(2 C . .
SigiVj ':120C/C:--
Sit.Well Location:. • . . .. 157 n•-.,29.51.. .tf/oc.' .6ainy4c-:. .- .
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'Facility/Owner Name . ' . . . Facility ID#(If applicable) ' .
71:1).•r),i 11 14 ././S •.1$:4: '6ii&414rX4iryt;JN/j e. .: i .: ' ..ft-:- . . "-. .a'
*PhysiearAddreas.City,andZip,
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Count
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. .Parcel Identification No.(PIN) ; ' • •• , • ., . . . . - .- , " ' - - - ..,-1-•%, ' . '
brdriryr-len Prt74:wairzla 1/4m.-• .
.5b..Latitudeand longitude in.degrees/ininutes/secondsor decimal degrees:-. . - - . ' ' • • . '.• ' "—- ww.D.v.tr•tOC. • - .
(if well field,one letting is sufficient) -.
22.-.Certlil flea:.N -. . i. •
W - • 1'• . • .e- 1 i 23.?2. (I:
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6..Is(are)theNCIIKOZermanent. or.:Diemporary: • . Sigaatiue of Cerdfied Well Con ctor . .
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.Bysigning ibis Arm,l•hereby certify that lhe well(s):Wio(were)eonstructed:hi accordance••7 Is this repair to an existing well :Dyes•.or.01e • •With.15.4.NCAC 02C.0100 or 13A NCilt 02t'.0200 Will ConStrOction Standards and that a .• ,
•• •(Phis is a repair,fill Out known well construction infiirmation and explain the Maitre ofthe. copy alibis record/as been provided M theittd1 owner-.
repalrimder#21 remarks section or on the back,qt this form.
. 23.:Site diagram or additional well details: , . -. ' • , .
8.For Geoprobe/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
-constradtioni.only 1 GW,I is needed.-Indicate TOTAL NUMBER of%Vella- • .constniction•detailk.'-Yon May also attach additional pages if necessary.:
•drilled: .
.SUBMITTAIANSTRUCTIONS- ... • .
•9.Total well depth beloWland.sarface:' .2.‘-,/57 •
(ft.): ,24a. Foi•All Wells:- •SubMit this form within.30 days:al conipletion.of well .
FPr miiltiple yells list all depths ifdebrent lexainple-.3@200 and 2(ahl00') -
construction.to the following.
10.:Statie water level beiow.top o Of casing:. • : . • • - _ :(ft.) ' .
'Milder;of VV.ater Reiources,'Ihforination-Processing Unit,
yivater level is allow easing:tie''+''
1617 Mail Service Center,.RaleIgh,NC 276994617' •
11.-BOtehale•dienieten G :.0..1 .. _ _,. - -
24b.•FOr Injection Wells :in additien to sending the form to the address in 24a• ,
above,also submit one copy' of this•form within 30.days of completion of*ell-
12.Well construction method .AiZ.• JR" •i'l' • • cOnstruCtthe ion to' following
-(i.e.auger,rotszy,•cable,:diret push,etc.)-
• • • "• . -DIvIiItitiot Water Resonrces,Thiperground Injection Control Program,-
FOR WATER SUPPLY WELLS ONLY:. 1636 Mail Service Center,Raleigh',NC 27699;1.636
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138..Yield(gpin)• - .'/. . . Method• of test .6.1b1 h 4-; . • .24C.for Water.Supply&.lidection Wells:- In addition to-sending the form.to to-
the the saddress(es) above,.also:submit:one copy of.this form within.30 days of - -
13M,Eilsinfection tYPet- -p. Tu. .. .Arimunt:1)4 67-- • ' •Completion of well:construction to the'county.health:department Of.the county-
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•Fon*GW-1 • . . North Carolina Dcpaitmeniof Emiironmental,Quality-DiVision of Water Resources 'Revised 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
Record of Construction,.Repair,or.Abandonment of a Well
Address of Well: 2911 Gh V),Sit
77
Gller�VStjte- n9,C. LATITUDE;3_.
Well Permit Number: 23-O S-i4t 1)iz'.-OO 2 S"i : LONGITUDE -
Well Contractor Company Aqua Drill Inc. Completion Date / A3 72.1 :
Total Well Depth: f.tS ft. Well Yield itJ ;gpm Static.Water Level .6 0 ft.
• Outer Casing Material: 501Z:-2 I 1 P J,C Formation Log
Casing Diameter 'fio/y. in: Casing,Depth q0 ft. Depth . Description
From:0 'ft.To ft: gC
Cljg�
Inner Casing Material: From:' :ft.:Tos '-ft.: $p�►d.' Ed Gr
Casing Diameter: in: Casing Depth:.. ft. "From:$S'ft.To;2' ft:• : j3 In e 41240I4e
From: ft.:To: ft. : :
Grout: : From: ft:To: ft,
Depth : :Material: -:Method' From:: ft.,To:. ft:
Prom:.0 ft.To 20_ft. ..C r eZ From ft:To: t."
From:: :ft.:To: .ft, -
Front ft. To: ft. I.-. .. . .
From: ft.To: ft: From ft:To: ft. . ( .
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Water Production Zones - 1
Depth::21Sft: ft.: ft.: ft. ft:. . : ; ft. . : ft.
:Yield:- JO. gpmgpm; . -
:gpm gpm gpm .gpm gpm
Method of Repair . . 1
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Method of Abandonment: . +.
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(hereby:certify that this. well:was constructed,repaired or abandoned:accoiding to the Guilford County Well
:Rules in:effect one this date and that a copy of this record has"been provided to the well
owner.
Welt Contractor! ?Z Certification# 2080-4 Date: ) ':. .3 72. `I
Record of Pump Installation.
:Pump Installation:Company: i)V`l•1\. I c. f - Completion Date: 1 . 1 • .
Pump •
:Depth:: VC) :ft.:Static Water.Level: . c � I ft:
PumpBrand ' "\'C L " �arA P iDSe i
pp
_ ��� 1�'ump Size sting !4:hp.i l� gpm
.SW`ou- .
andR
I here y certify that this pump was installed and wellhead completed accordingto the Guilford County Well
Rules in effect on thi a
ndat a copyo this recoid has been provided to the well owner: I
Well Contractor: • / :Certification#: a 1 Date: .-WrfL-
Revised:January 1;2009