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HomeMy WebLinkAboutGW1--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: • • 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.