GW1--02761_Well Construction - GW1_20240506

Pdnf Form
• WELL CONSTRUCTION RECORD(GW-1) ' ::. • • _ For•Internel Use Only• .• •-• ''
•'1.•Well Contractor Information: •.
: GaiyTliompson 14.wt'r razor s f
- ': • Well ContriiotorNerao .-.. • ° ' .: . : •, • • • FROM"•'� • T•O , •.. . 'DESCRIPTION . - : .: :
:• ' ' ':. • '. : . ' :•: . ' • - ; .' .Sea:tt:. •584 ' :Fro.4o'r: : •a• 6PIi • • .
NC Weq Cont'raetorCerlifioahoaNnmber
' Aqua Drill,,inc : :. . ' .. . • ltrnNiawn e•a1.e)oltLtr�c.eafap
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..... 2.Well ConstructionPenidt#-•-a3'10.WN 1=%R-oO y 3 2-.•_- . • FROM..-- TO: -. Dreniamt . MA1ThTL '
•' . • :List all applicable sail c l motion pomitt:(1,:a.{!!G cow*,bvtg.PaHmrce,.ete)-:. • '.:R.- •'.tR :._ In:• '-•• • • •
3:Well Use(check well'use)e.. :'.. • :. `. ' ' . ;:. .� '•• • ' .� ::. ;iri. :i
Water SWatet Supply Well:- .. •
' xi ;i cultural. •• , .••••.. • • DMuniorpaUPubhc• • .. . ._
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M- � To� n>wnn,,LBs� slorst�� 'retciavrss . :uLe't>AtteL '
: I Geothermal(feating/CoohegSupplY): OResidenhalWa if*Supply.(eingle)•• : - .ft. - ' .tl. 'to..
': N IndostrIalCammeieial:.• .• • E3Residentiai Water Supply(shared) " • • '• ; J
'',Inaction.• . . • ' . .. . OUT • •
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Non-Water supplv:Well. ,...' . • .• . : : • . a t.r�. ao• ft. •?MATERIAL. : .•
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' .•InJectian Weil:. . . . • . .. . - .. • • , '
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Id ' '•-' StoiageaadRecovary.• SaliottyBamer • -FROM•. -To-TO .- • Mega. -
'•. .'.. It,' feiTest•: : ..f4'. .. . :-i .. . . ' .: : ,
- � ssueL�te�ivr METHOD
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StaanwaterDramsge;• : ' : � •
-.' -.: . •- N :, entalTocbnology. : : • ' : • : SulrsidencdCoatml' . ¢: • . .. • et . .
;:. ••-: lif Geothermal(Closed Loop) -.: , •OTracer::.: :•'•• • : : :. 20.DRILLING LOG(attseb ad4UQoaatebeetis itsecmery)• • ' • •
Geothe:mal(AoshDggCco1mgRcdtm). '"�Otbcr(esplaiamider#21'Remarks) FROM: (e6'n".rt en,.ont.eetbaao.tr.fa�eta)__...
• M TO � DEsct�r[oA
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21 RI;MARH$'
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fib,iiitttnde sutd longitude In:degreedminuteslgeconds or decimal degre a:: • '" - -
-' • -:,i •Orwell field,one latfong,is sut cleat) ' . ....• .. . • •. . . . . o - . . .�. . . ,� �',•22.Certifleation: j •
36 14' .i6,q • N. ..._042, .I 33."rd41a , : . ..w : ::• ..i • '
6.Is.re•the welt s) -. Permanent or Te •Sign aof. •,ell ° p l cJ�
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. . :. . .. . i '- fanri'l.heri:6y- than the ne!!(aI�a-(were):cnruduetadtn acoardanra.`
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repair to>tD a:trtiug�►dl �Yei at• �NNo• �' wltli 13ANCAC 02C:0100-orlSAIYGlCOIC.Od00 i7egCoasdacllon 9[aedmde and theta
Ifthls trarepaU fill orithgawn well consnuctbnhdorriwtionand erplab(henatu a gilt*. capygjthis reconlhasheerr prvv gd.ro the uylo,wwr; • • -
i+epairwz rr$2lreerarksaecttonoroatkabackofthtsfbn,j. j3.s402 •
wend .
• B.For•Geo • � tWpam or additonal details:
. .protie/DPT or Cloied. oop.Geothermal.Wells bevingtbe same You may use the bade of this Fag.;to.provide additional well site details or well:
• • .'constna#ion,;onlyI OW lisnre nd,•IndicateTORALNUMBER"of wells ' Cnatiuctioadetails:..Youmayalsoattachadditionalpagesifnecessary, • :
$UBM• 1TTAL• INSTRUCT•I•ONS ; •: •
9.Total:WO depth below lend surfeee- •- 6 5 ' :'. -
•
. ' -Pet. waits lirtalldoliths{iff/li sal(exempla 3R200!wai2@i009: •- 0.days of,completion of.well'. :
) 24a.�+or All'Weld Submit•this foam within.3
•
:.. - ... ;conshucticntothefD]towmgE . 1 .. -
. 10:Smtic water level below top of casing: 60 - {it:): • ' •. . DivMon of WaterRemnrea,Information Peotuosing Uidt, ' ' : :i'
if vaterlevellsalwpacu hrg use+" • ' . • Ce to Ital
II-Borehole dbunebere ' :� ' :� n •
�.. . G.,�! e1gb;NC t7tD9?-1617
1617.97a11 Service
a') 24b.,Foi•Infection.Wells: In adds on• sending
. . ' ' • � � Dn.tO the'sddress in 24a
12.Well cons ruction•method:- •: ROfA A�F also • it e copywithin30 days of completion of well.
vy: , . - - construction hefollowh
(Le.aoBey mtmy,eab}d;diraaEpuab;eta) form. .0
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FOR;WATk,R SIIPPLY•WELLS ONLY
Uncle n Program;
: . . • Center,Rtdeigh,N 27��16 6:
Division of Writer Rao
itr�6 Mail Swvlee
' .13a.Yield •
.(gpm)•. a . : : • Method of tests .CG 401h41t t e . 24e.Poe Water:only'8c�alszdtnit fells In addition to•sending the form to .:
•• •e •' • •• the addiess(es)'above, also:submit one cgpy of this Point:within 30.•days of i•
• NTN.1O-�13b.D1elnfecUon types ° AntonRk I`•02 completion of wall"canstniction to the ceiuntY health department of the county • l
where constittoted, •
PonnOw-1 • Nor h Cam]isa Depattmeat ofBnvQonnientel Qamlity-Divistoa of Water t3amrroea ltavlstid 2 2Z-2016
I

- -- .GUILFORD.COUNTY:DEPART MENT.:OF PUBLIC HEALTH! """
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:, : .• . • : : o . ealth,-Water Quality:Unit.: ".: .
. . . . . :. D onmental H .
evasion of�Envir
- •" 00 W.Market St.;Suite 300, Greensboro;:NC.2Z40.1 • .: : "
Address of Well:..i 010 fleck Q'ot154 Dc:'.S}oketelate IJL A1351 :LA1 TUDE•3 4 0
Welt Permit Number; a3 10 WNHR" oa 93'i.:. .•. : LO G1•TUDE eo- . I:.. •..33• :,•.2L1`1•a ...•.,
•
:Welt Contractor Company: • " ' -• A :br• ill f Inc. _: • -: ' .•. .• ' '.'Completion:Date: - '4 4.l_dy: :"
Total•Well De th: . '635 ft." :- -Well:Yield:. 0,- -gpm " .'Static Water'Level• •60 .. • : ft:
:bider ci g . . • .Material. PVC :: .
." CasingDiameter: 6:25 in Casing Depth _'I , t,:: ••• •• :.Depth �o tm ®la.l�g
: . :.. om 0 ft.To 10►rr} -:- . . .1
. cri
'Material: :. � .' ".. Fr ,
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g - Frown ;'1." ft..To. I3. ft Ia+tiy_1R i Sot1 -
: : " Casing Diameter:.. . . in:.. :Casing.Depth ft From -'13 ft:To_y8 ._ft " 6re'rti4e :: - -
:. -". --::: : . . . .: : •• From yS ft.:To 6*.ft &ro►:ni1e
Grout .. .""."".. :From..... ' ft:"To:' • ft..• :"
•' Depth- • -. " Material Method From: ft..To • ft.•• •
From .0!-ft..Toc:aO- ft...1. • ".Cement::''"PaAia_'j1Trv�k. .From: . ft..Toi :•. • " - ' : .3
. . .From .. .- ft TO: .... - :• : : ._..' - • • ft• ..
From:•_: .ft:To�: : " ft. • .. : -.
'From • ft:To ' ft-
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:.. .Depth::582-" ft. ft.• - ft. ft.•.• ..
: :•Yield: '4 gpm" . • ' .•
.
- - gpm � •gPm gpm gpm.
:: :Method of"Repair '- : • - . . . . ' -
- . • Method of Abandonment: _• - -. -• • - . . . . .: :
-1 hereby certify that this well was constructed,repaired;or abandoned according to'the Guilford County Well. "- " - .• :
: Rules in:effect:ad this that a:"copy..of this record has been provided to the well owner.
}
:Well Contractor: yam,.+. �. / Certification#: " yy18-l1 Date: .=1a'd41":.::.:
. Romig*:O' :f 6Eill 11 ) 1(nstjDBc' it © 1 . . .. ..
' Pum Installation Com an -: �. q .; ("1 - .
P - A . Y � � Completion Date: ."� --I����
•• I
- Pump Depth:. . J�.bo:. -I Static Water Level: " (42. - . ft ' -
-- z f
Puinp Brand: .cf LA �� -rip. I5 ump.Sie'and Rating. �V� 5
"'I hereby.'certify that this pump wsas installed-and wellhead completed according to the Guilford County Will - 1
Rules in effect-on - date" . ii that a copy.o this,recordhas been provided to the well'owner:• -
Well:Contractor: C ' Certification#:� 0� Date: /".),p� . 0 •i•
: - :
.Revlscd:January 1,20081