GW1--01051_Well Construction - GW1_20240212

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WkLE.CONSTRUCTIONatoRn(GW-I): • ••For Internal Use Only
.1.-Well.Contractor Information:• • _ . . ' i
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Chris 14 WATER ZONES King KFng-.
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- • .FROM •TO ' . . DESCRIPTION ' . - „ ' ' •-
Wall COntractor Name.
2080-k. - I, • . . • •
• /qtY".• lq 1. :JO 1.6-te,r9. .. . . , •• •
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,.•NC Well Contractor Certification Number
• IS.OUTER CASING(for multi-cased wells)OR LINER(If applicable) ,• . .i .- '.
Aqua.Drill,
Ind. . FROM . TO - . DIAMETER THICKNESS,' • •MA'qRIAL-,• . . •
• . - • • • - : . .. Ir:)... . ft": :Cif 57 k la. 5 i.)I I I- ...ra,cf-- .'..
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• • company Name• - -
6-). ....,eu......ry • 16.INNER CASINO OR TUBING(geothernid closed-loop), - •2,Well Construction Perthit#ii .q.-51S".- /13 14 K":13',1>,.. FROM' 'TO , -DIAMETER' ' •THICKNESS• •MATERIAL.List all applicable well construction pbrinitn(Ce.•VIC,Como,.State,l'Orlance.etc.). - ' ' • . -ft... • 'ft.' ' :. In.
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Well Use(check well:use): •. . !.•In.. ' • • . •
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• Water Sfippiy Well: ' • SCREEN
• • PROM' ' TO : . :DIAMETER: •SLOT SIZE THICKNESS . MATERIAL . .
. ... Agricultural' . • .. •1:11Menicipal/Publie ft... : . ft.. - ..in., • •
Geothermal(Hoating/CoolingSupply).4tesidentiat Water Supply(single) '. .ft. : :ft... •in.. • . 1 .. -.• • .- . "
Industrial/Conimereial- •DReSidential Water Supply(shared)..
111.,GROUT.... . . .. . . : .. : :. .•• ' .. . . • •• .
. • Irrigation• • , •, . . . FROM - TO ' .MATERIAL 'ENIPLACEMENT METHOD&AMOUNT'
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. ' Non-Water Supply Well:- - • . "' A: . ft'' .de i,?ielo:),
. - Monitoring.. .. - , • DRCcovery . • . ,.. - . ,- . . it: • • - ft. . . .
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• ' • 'Injection Well: -- • • •
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' - ft
Aquifer Recharge • . . OGroundWatciRemediaticnt
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. • .19.SAND/GRAVEL PACK(itapslicable)• - - • ' : : : :- " .. . - . •
• . Aquifer Storage and Recovery: .rjSalinity Barrier ' 'FROM' ' TO - . 'MATERIAL ' . • .. 'EMPLACEMENTMETHOD
Aquifer test _. • • . DStormwater Drainage ft. ft.. . •
Experimental Technology . OSubsidence Control it. •
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Geothermal(Closed Loop) .DITracer •• '20.DRILLING LOG(attach additional sheets if necessary) - • • - • . " -.- . . ..
.FROM ' : 'TO - - DESCRIPTION leator.tesdness..solikeett iv/margin size.etc.)
• Geothermal(Heating/Cooling Return): nOther(explitimunder#21 Remarks)
. . LA. , .(:).; -..ft'.. .....3- ...it' g e : .C.1.1g y . .
.i, e_2, •e7g," '
4:Date Weli(s).Conipleted:)."2-7: -70k7Well ID# •LC?t. l' I'. ' : .ft* : qC). fk SAN d.,• iZeck. . .:' . -
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511,Well LoCation: • 90. ri.-- -9.4151.. ;13)3t -6 a ttim le. . ... _ . . . .
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ft.- - I,4-......:ch....,tz i . t.,.._ •,c ---;.. . •
Facility/Owner Name' * Facility ID#(if applicable)
:S.7 '6).i'6e OA) .174: 6-..:Keero /661.2.0• • • • ••ft•-• . FFE3 i 0. lnq
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Physieal'Address,City,and Zip
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. - . - • V.-REMARKS . . •- . ' inkrrAnie,.3 ,:....,..- • ..,-. - • -
• '670';I 1-761..e-1. . - • -
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County. • - ' Parcel Identification No.(PIN) ' ' - ' - . . DWOMOG . .
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'56.1,:atitude.and longitude in.clegrees/thinates/seconds Or decimal degrees:-. : . •
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(if well-field.one let/long is sufficient) •
. '22.Certification:. • ' . •
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. .. 6.Is(Ore)the,well(s) rinanent or,:Oriemparary: . Signature of C fled We I Contractor ' 1.•
- - - • - Date• '
. ',By signing this folio:1 keriby certify that the well(s))vas:(vere)Construcledin accordance . .
1 Is this:a repair to an existing well : MI Yes-.or MO "with.114:NCACO2C,0100 or 1.(A NCAC,02C.0200 Well Construction Standards and that a •phis is n repair,f11.1 out bully,irell construction information and explain the nature of Me. copy ofthis record has been provided to the well on net.
repair under#2I remar4secden or on the back of this(Orin.
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.
construction,only 1'OW-..1 is needed..Indicate TOTAL NUMBER of wells • •construction details You may also attach additional,pages if necessary•
'drilled: -
,.,............ 'SUBMITTAL INSTRUCTIONS 1, ' ,
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•9.Total well depth below land surfaces • .9.- --1> . . -- . (ft.).- 24a.for.All Wells:- 'Submit thia flerm within.30 days'or completion.of:well
For multiple we/Cc list all depths ifdtfibrent(example-:3W00'and 2@100) • . ' • • •
constructron.to the following:-
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-10.:Statie writer level belOwlop:of casing: 6:12: . . • . •ot.)• 'Division of Water Resouries;Information Processing Unit, .
If*wafer level is above casing,use"4."
- .1617 Mail Servide•Center,Raleigh,-NC 27699-1617'. . •
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11.•BorehOle•diameter:- • 4. '. ' . (hi.), 24b.-For Injection-Wells:."In additiOn-th sending the:form to the address in 24a, •
i i- . • i , ).. . d ..1. aboVe,,also submit one'copy of this form within 30.days of completion of well
12.Well construction.metliod:. r Ti - . • • - . •
construction to tie following:
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(i.e.auger,totaty,:cable,direet gash,etc.)•
. . , . •Division of Water Reionrces,Underground Injection'Control Program,-.
FOR WATER SUPPLY WELLS ONLY:, .'ll:9*'V ..
1636 Mail Service'Center,Rileigh;.NC 17699;1636.
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13a:Nieldlgprn)• • ./.-0 Method- of test: tr.,•' _1._ -'•-,.'---!.----. • • ..24C,'For Water-Suppli,&Infection Wells:. In addition to sending the form to
. the-address(es) above,.also.:submit-lone copy of this-form'within.30 days'of
-. i3b,.Disirifection typei. )/.rid .. Amount:/6*. ()Z. : completion- of well:construction M.thai county health.departinent,of the county
where constructed.•
FormOW-1 North Carolina Department of Envitonmental.Quality'.Division of Water Resources 'Revised 2-2272016
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GUIVORD:COUNTY Dl3PARTMENT OF PUBLIC HEALTH
Division ofl3nvironmental 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: : . •
. LATITUDE 3
Well Permit Number./9 -03 -6a/of-a •!- o 3 etc'? LONGITUDE
Well Contractor Company: Aqua Drill. Inc. 'Completion Date:i -:29.--,2 4
Total Well Depth:2.9 ''S." ft. Well Yield:/0 gpm Static Water Level: 6.0 ft.
Outer Casing , Material:
FormatiOn Log
Casing Diameter 6.79 in. Casing Depth: CIS- ft, Depth Description
From: 6 ft.To:3 ft. . Re.," Chil
Inner Casing .Material: From:..7 ft.TO% ft. 5in..id Ps c it
Casing Diameter: in. Casing Depth: ft. From:9():ft.Tog-IS-ft. Zji.LCLrLABILZ '4C
From: ft,To: ft.
Grout Frora: ft.To: ft.
Depth • Material Method Flom: .ft. To: ft.
FromC.):. ft.,To::;0 ft. C en,e1u4 Fax-Z: From: ft To: ft.
From: ft To: ft. • From: ft. TO: ft.
Fronk ft.To: ft: From: ft. To: ft.
• Water Production Zones
Depth: )90 ft. ft. ft. ft. ft. ft. ft:Yield: 10_.gpm _ gpm • gpm gpm —•gPm gPm __ gpm
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Method orRepiir-I ---- :
1-ccr- f'.:. 'f. ''2 -'•
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Medled OfAbandonMenti'"'"'
Thereby certify that this well was constructed,repaired,or abandoned according to the Guilford County Well
Rules in effect orrthis date andthat a copy of this record has been provided to the well owner.
Well Contractor • Certification#:
elia#1 2080A Date a " 4ie1-a .4,)ii
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Record of Pump Installation •
Pump Installation CoMpany: L -z,..1 . 1 • ."-- -' -1 ' Completion Date:
Pump Depth: I SO ft. Stade Water Level: c-k.D ft •
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Pu%n.0.- B5ra . .
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P l OS07 Pump Size:and Ratingqhp_ _D; gpm4 _ _Ihere y certify
kat s pump was installed and wellhead completed according to the Guilford County Well •
Rules in effect on s that a copy of this record has been provided to the well owner.
2_.cy/
Well Contractor: ' / t Certification#:,; (-..1Cie ict- Date:)/(5- /t...-. pi
on j
Revised:January 1,2009