GW1--01049_Well Construction - GW1_20240212

i
c . Pr1nt;Form
. WELL CONSTRUCTION RECORD(GW.11 ` Far Internal Use Onto:-- F;
.
1.WED Coalrachr Int ralsatloD:
l iI ,
David Belcher. 14.WATER zoNES . w i'I q • _ •
WellConhactorName' FROM - _ TO: DE8CnirrrcoNl
44594-A . AO) $ IQ'N o' ,:_o9Od1PR ( rt l.urn)'.
.
• -f tt.- ' ' •"NC Well Cantacter Certification Number • - I'
• ' IS.OUTER CAKING(ibr ooitlsead IieDs)OR LINER Of gale) .
Aqua Driii,Inc:. ' - PROM' - To• ' .DUD1LrBti Ttucla s ):MATEWAL-
. CompanyNemro . .' : - • O . 5 't I CCo ;in'.. s1R,9i -I ¶ C . : .'
- •16••INNER CAMNG OR TUBING..(aaeotheriied dotedd000l
Z.Wet Constructiona3
Penmit'N:. -GYe.•6)AJkS •6f6R76 - FROM - • TO ' DIAMETER. ''" :MilaLVELT •. MATERIAL '
LW all opplk�abletiell constntetlanpermite.(Le UIC,County,State:Variance,.eta) • '. 1t it. "
. :3.Weal Use(check Well uue) - - • .-!a• :-
Water SDPP4 Wept - • 17 SCREEN . . , . •
A oultutat METER- 'Star tor:
•FROM '•70. DIAMETER' 8 THICKNESS. MATPAIAL• '
.0 g� • 0- •ctpitYPublio ' , .. s. ..• .ft. ts. ' . r -
.0Geothermi(Reating/Coobng Supply) t. .Residential Rater Supply.(�1e) ". : ' .I .- .
OrnduehiaUCommerciat: Residentlat Water ' - - " -
0 �PP(Y(shared)`, Te.eRooz. ,..',: • ". • _ . '
1`limitation _FROM TD _ MATERIAL 1, ' .RMPLACEMENTMETRODaAMOUNT. '•
. . Non-Water Supply Well:. ' ' • tt;. ' 7t n
Monitors "
!� .. ?':.. . 'C�nefrF.; '. ; t'bLLC"w(4h 7rucK
action Well:"
uiferllechaige 0(imandwatcrRmnediation. • iG I'
AO*Storage EndRecovery- OSahnity BaQier e:SAND/GRAVEL Etat0flowaelble)•'• ' •- •. :
FROM ',. To' , MATERIAL ,. .EsIELACENEHrragman-
AejtiifeeTest" 0Stormwaterl)Iainage. t6 .. . .1 Expetimentai Technology:.- . " OSubsfdence Control• ' tr: :D: `.
• OCieoihermal(Closed Loop)' Tracer • . - '
O• . . 30.DR1LLIPIGLOO(atfachadd[tlsaddtcebtfaacasay) .
• flocothermal(Reatmm/CoolmgRetdm) fOfheC(eaPleiaundor#21Rmaerks). FROM To • DFECRIPT1ON(edorllarsnm.wliro ove..anv etc..'
SO ci ; •4.Date;Well(s)Completedi 9;5%; ; . WellIDI : '•• Cf . 2d 56. n. IG •Sitf.. ' ' '
8a:Well Locations" iw
Jr ' $rj (p rke.
. - Stjrnn--filavelAptien4 .- :. .- ;.. 55 ft. an . •'lt,re 6tirint4P
Fae¢itylOwnerNeme -natty ID#(ifepplicable): : • ft•
r� :mR' • 1'' ' ' •• »�.R.. ..•.,,y: .
L,9) , 12905 :Mrhnpa.g_ C &coorgboro jilt: '45s . -R.•': ' ' IL : 1-� LiI.':i
' PhystcaieddITI Cy.end* , - ' . : K _ . FEB: 1 ! 202A 4.104E ' ' . . • .S1REMARS
•
County . .Penal fdeinlficatlanNo.(PIN) • '`�i;/,:::_'t ':nea nv^'f:N+ecl eels-Ugit
;Sb.Latitude and longitude In de@eees/minuteilsecandi or decimal,degrees: • -' '•
` - ..
(Jewell Held:one tatllosa is sufficient) .
. '22.Certiflcation:•.
• . ;2t� i21.5 :3-• N. •..79° 49r._3;3tt. w. 9•'7 a3
6.Is(are)the well(s) ermadent or.OTemporary. •' silts e lofCertiflea Wou conlmctor r Date
. • • Byaigning the formal hereby ce• rtify that•the well(d)was.(xere)constrrrcied Si,accordance •
' 7-Is MS a repair to in existing well:•.DYes: oi• No: with 1SA NCAC 02C.0100 or 4SANCAC 02C.0200 Well Conduction Standmds tied Milt a '
'Ift*freiriepnir:Jif(outhem wellonigrathonlnfbnmtioa and eipfotetheaoamrofthe _ .eonyofa&re.nrdhaabeenpray.iledtatheurllowner: . . .
nepatrwttlr#2lnema,*,aectiannr.en the baekofthtsJin ' .SiEediage.•:, addidoaalweftdetails:,
•B.For Geapiobe/DPT or Closed=Loop:Geothermal Wan having the same_ . •:You may use the back of this.page to preside additional welt site details or well .
.construction.only'1 OW 1 is needed..Indicate TOTAL NUMBER of wells'. Conshdction details.Yon may also attach additional pages if necessary.. '
•
"SUBMITTAL 1NSTRUCIIONS c : . .
9 TOtal wet dePih bele*land.euefeee oft/5 " " - (R,)•.'24a•*Or AN welts:' Submit this them'within 30 days of.completion of well- '°- °
Fbrmehiple loth llataudepthalreff (�reple-3f)200'042Q106). •conshnctionto.thefollowing: • l'. 1 - -
II i
10.Startle water level below of f '.
�P. casing: UO
'' •(�) Division of•WnterResomceo,IntormatioaPrat�sshtgUnfl;'� -
ljwaterlevella aboveoartriE tese+^ ' 1617 Mall Strike Center;Rslelgh,NC 27699-1617
IL Borehole dmrneter (Il (tu j - p 1,,-r.,:, �, ; .,; .
24b.For Infection wale:. ID add�ioa to'sendmg the form fo tho`addross'in 24s
• t -- above,'also Submit one copy'of this form within 30 days:of:completion of well
(La weft rotary ca tle, method:• :'fti[f h Air. constntctioato"the fbuoa�in ' `
. •(Le,a.2*eatery,in/Ma,direct OA,eta)•. ,' - . . :"y
. " :• • ' Division of Water'Resourees;•Undergroand Injection Control Program,
FOR WATER SUPPLYtWELiS ONLY: . 1636 Mali Service Center,Ra ilgb,NC27699.1636 .
! yf e
13a:Yield(gpm) '._ .� -. -" ' - 'Method of test:.Ce..kh +Ti MR ' 24e.For.Water Suoaly&:Inieetioln:Wellq.: In'addition to:sending the fort to
'• '-. ' ' - e . •: : ' - "the addtess(es)above,-ilso.iiybmit;one`cagy of this•foim within-30 of
. 13brDisinfee@on types N I R YO to .,Aniodnta '(fiea-- , •co pletion"of.meli`;constructton•to the county health.department of the minty •.
Where oonehrmted •
Fein OW-1 North Carol maDapireitentofEmlromnenta1Qantity-DIvtsionecW terResources. RovIsed •222016 • ,1'

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: ')903 l- ennel:5: SVI &ccerlshora,Air 01465 LATITUDE 3k 12 ', , _.
Well Permit Number: , OCo-l aN f'R-`O 1aW LONGITUDE .t9: yg_ A. ., q
W ell'Contractor Company: Oa 'Dill". 7.nr.' .. Completion Date: . q: a3
Total Well.Depth: Aa5 ft. Well.Yield: 42O gpm Static Water Level:: 'WY ft.
Outer.Casing Material: 9/C - Formation Log :
:Casing:Diameter: ..P5 in: .Casing Depth: 555: ;ft. Depth Description
From: n : :ft.ToL fft.. Lta•
Inner Casing. .Material: From: as fl:To:_ ft. .; S .1
Casing Diameter: in: Casing Depth: it: From: 5!) ft..To: "55 ft: :lierf,
lie 'O.irlin'.
From: 55 it:'To:.Ali ft. 'Slue Ksrin '
Grout• :From:• f:To• ft..
Depth Material Method- From: ft.To: ft: . .
:From:.O It To: AS ft. rre bus' 14111*K From: ft:To: ft. •
From; _ft:To: ft.: From: .ft.To: ft:.
From: 'ft.To: ft: From: ft.To: ft. '
Water Production'Zones .
Depth: : I O. ft.: . . ft ft. :ft. _ ft: ft. . .
Yield:. .gpm. itgpm gpm. gpm :gPm. . - gpm gpm
Method,of Repair; -. .... , - :
. r
i
Method of Abandonment:
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l hereby ceitify.that.this well was constructed,.repaired;:or abandoned according:tro 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: O . . '
Certification#: U5AU•4 . Date:. 9'.7•a3
Record of Pump:installation
Pump,Installation Company: .`.I'\ ,--ram. ' Completion Date l I 3u1J )
' Pump Depth: 1; (5740 ft. Static Water.Level: Q-0., ft: :
Pump T' m'1a--P1'o.5U`�P � t,i1 I4 -
p toPamp Siu and Rating;; hp gpm:
I here y certify that this pump was installed and wellhead completed•according to the Guilford.County.Well
Rules in:effect on. date d tliata copy of "'S record has been provided to the well•owner.. .
Well Contractor: 7. •
Certification#:c:;) ;1C�'er Date: 2.%.1-77-17-7Y
: Revised:January 1,:2009.