GW1--02763_Well Construction - GW1_20240506

Print Form .
: WELL:CONSTRUCTION RECORD(GW).). . : • ' .'.:• -. For Internal Use only:• • •• •• . • .. . • •-
1..Wel:ContraetorInformadoti: . . ..
Gary Thompson : It WATER ZONES :�..,
.'Well ComracrorNwnc-:-- -: - • ' •TO :. D88CRIPrtON-
• •PsoM. .
4416-A.: " . . .. • �?35 ft' 1456 ft :..I. ftp.r,h •r- -c•to� :
• . : : GP�'l
NC Well CoaoactotCtartificatiouNamixr :. ' ' . �... - :. -_ . .
• . • 1S.OUTER CASING mil ..ga •
-
Aqua:Drill,.Inc' ::: • .. r -
` • .' � '�.� :' .. i . .FROM .. _.TC O�•'_- .DIAMETER,, )
�a�y / R(!f able)
- 0.-f ' 16:_.I. 6•!:• 5 tn: $-DR'.' PVC
CoinpauyNamo :. ..
- 1�- • • ' ; • 16.INNER CASINGOR TUBING(asothermal dried-bap) ' • ' . • - - '
2.Well Construction•Pertnitti • • al p,U" s 3 Ms (5u�0 Morel . • -To •:--- -Dwm TER- •Tml:raal$s-` :MATERIAL' ... '
: '• • . .List all applle.abla trelleonstirictlonpemritO(i.e.VIC,Cavity.SYate..Parlance e14 'IL' fL• ' , ''la;:
• ''.: . 3:Weli.Use(check welliuse); : •:. . _• . • ' . .. : . •• : - : -::i-!u.' ' . . -
•• 11 A eidtlal 00usicipaUP ublio -1FR7OsR T.O. •D.IAa t-s,rsna
•.8IA1'8178--' 77IICinO>88 •.a ft g" a•
•
rATe:- .: : ' i Geothermal(Heating/Cooling Suply)• ResideabalWaterSappY(a1ngle):• ' .-; .-' ••' In.• . . • .- ` - Rur:
-- :
•
lil duetriaVConmlarcial• D• • •Residential Water Supp1Y(shared)'• rn,
.' .: •- .•kdj tion+• ..•• . - .• • ' .__ '•• : .• .. 1 ; -.PROM-• .•- , . . MATERIAL... •: IialPld\CEMP.IYT METHOD&AMOUNT.
'. •• Non-Water Supply'Wei: .: : :. .. . I• ' . • ..ft � ` t::. :-C.ti �, ,o�irta'V`i t ` -,,V��C
I*cdon Well i '
tit Recharge.. : :.. circun8nrater ltertte ,ati i '. . .
. 19.SA1ND
. : la ' Storageandlceovety. LSalu►rtyBam • : ' PRoa1.. 1 TO, • • c. • i amaioon :.
• •lit..• Test • •• •• • •' '•:• .. • �Stoimwater Dtainege :l • •' • -..I • ft. • • • .. .
. ■ :, ,- Technolo.
. . gy. .'. • • • �8tihtsidence Control
1M Geotlutmal(Closed'Loop)..•:: : :. []7taac : . . ':. e•-• •-.• : 20a0RII:I NGLOG(attachidditonalafmtaIfamessary) • --. •
•
deatha�ial(Roabnr,(Cool gfctum)-.. ()bilier(explaintmder#21t`Rraiark s) :FROM• TO' --. •- D1 tION(mmr rn�a.wvt.!came'F.mrhr'ae.) -
4.Date Wef(s)Complmted 4:46-2 . -WeuDm •4•• 1 .: 3 ft; Qec S®:I...I • .. . "• .
. • •• So:Wen tomlone . : . . - .. - ••.: : .. ' .. .1 ••_IL R.
-• •Gred h 4 P
tre4rf,t_F.:in Gees: Hie•
v,...es • : • : ::. ' •1a ` . os. Gray..,4:11! -. .
- • Faothty/OwncrNema ' -. - .-.•' .•• •• -: '-Facility W#(iferpllcable) ' ' ' . ..
• :`aoi 3 Doc1�_Ridi lls.: :SAcs ei i . --• ; .
..P:ysialAddresa.(51y.:ndZIp " . . fi: 6�.._ 'rl• ,t?•i,t..a.- -..
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ma- o -c:2024::
Y .. . ; Pmal idcithncetton No.t(PIN)
21 REMARKS
''56.Latitude and longitude In degreeiFminutc,1.etoade or decimal d .. " • .i r' ::;,=i= ,, ' '• ':
,;• (ifwell field,one Wang . r - . , • 22.C�tleltlOn'. • . - .Da6 G1 JUv ' . .
0
6° i�`30i.� .. N:.. ._ 'so -.1: -3®oq°. ' W . : '.• .
6.Is(are)the wel(e) 11Permanent• .. or.OTetnporary . . . .. Date : '• .
s of ell
•
.. - • . . - •. . • :•By 6ignlagtlds form,IFierelyy(tie that iha nelf(s)not(�w,).constru ted In oceonla ra•.: ' •
• 7.Is this a repair town exlsllng hell . Yes:Or:iNo'' : :with ISANCAC tIZC`.o1o0 or ISANCAC 02C 0300:WeUConsaacNon Stairdmris and rhata .
' U'this II a.fapole fllouthlown web cvratrucilon In onnat on ande%ivWin the'r atu a Oho •.cwf tits rrcordhas.beenp o idedtd the i Oilers'-rs'-- • : • •. •
'. .
repair.under A21►emmdaaection of ore thabaekofthtsjorm.' ; ` '
`' - . ' 23.Site diagramoradditionatwell tolls:.: . .
Yon ca n dethe b Yon
8.For C�ecprobe/DPT or Qosed-Loop.Geothermal Well having tbesame • • 7pd�' P�to'provide additional.wol!aite�datails or well
•eonstructlon,only l OW-1 is needed:Indicate.TOTAL NUMBER of wells . : .. may also attach additional pages if necessary •
. . • -.,.__ . - ' , .. . . '}S1.1131V)><1'1'A141NSTRUCTIONS:-
: • 9.TOW well depth below•land atnface: ' 7165 -- - (g) •. " .Perna/hi*wgOsGstalldciths(fdt„game(example-•,3 200,'a0da®loo9 1. a.For A4 Weis: Snbmit.this form within 30 days of completion of.well . '
• . . COnahaet(t)nt0't110fo110wing .� :
•
10:Static water level below top of eatdnge .. ' 50 : (ft.) :.Division of Water Resour I,,antbrmation Processin Uni
irtinterkirl Is aboveaysfag we +'r . '.' .. . - -. - 1617 Melt Service Center,!Weigh;INC 27699-1617
11.Borehole diameter ' . G -. • : -(In:)' 246:FOI infection Wef1Q:, In addition to-sending the form to3he address in 24a
e •
- 12.Well eousfruction method • RO t+1,t':) A t r . above.also submit one copy of this form••within 30•days of.completion of well -.
(I.a aver,rotary.•cable,direct•Pinli.atc) . : c•onstruction 1 Y'on tothe following:. •- :
•
•
. . FOR WATER SUPPLY WELLS ONLY: •. ' j . .- - .. .
Dhlplan°Matar•
-. Baoanea,vu wRro�audec�>icomrorrrogram,
13a.Yield m �;: . 163tS Mehl Sennce Center.Ralelgti,NC 2769�163 6•
e :(SP ) Method of teat Govtoil:vi T 1 e1 Z4c.ior•Waite.beagle*do inleition Wells: In addition to sending.the tbnn to
e7 :- - . the address(es)above, oho:sub►nit one'1 Copy of tide form.vithin 30:days of .
f
• 13i Dlslutecfioa type: `7 O.`o.Amount: = OZ completion of well constatction to the'county health departazeat of the"cotmty
heie ttstiacted:
• FonoOW 1 . North CarolinaDePaRmeatofiinvironmonte)Quality-.DivisionofWaterltsodroa Ravised2-22-2016 -
•

.:: GUILFORD.COUNTY DEPARTMENT OF PUBLIC HEALTH
. : Division of alth,Water`Quality:Unit : : :
• . nvironmentaLHe
400 W:Market St.,Suite 300, Greensboro,NC 27401 - . • -
Kge:: l-,.: or coatOt ictiono RapkaEr 0:Abmndoitatitent el Ca a Wall : .:
. . : Address of Well 0.015 .Dock • iZstc13e lyf Kokesdo►ie.:213S1 LATITUDE 3 : '. .-
Well Permit Number :tO..:t,J1\3 Q. 00430 - .: . . LgodrruDE: ®. '30 01 . : :
Well Contractor Company:: -A c, ��.i11 ; ... _ CC
ompletion Dais:
. . , : _ -.. .
•
Total Well Depth '1O5 .ft:' Well Yield ` gpm Static Water Level: AO . . . - ft. : -- - .
: Oster Casing Material; P V G : Formation Log ' :
Casing Diameter:. (,= in. Casing Depth pi Fa: ft :: : Depth : Description :. .
. - • -From ( ..ft.To `1::ft. : QtA e le►y ! Oi.ri. . : .. .
Lunar Casing Material: - . . ' - . . Prom 1 ft.To i111: ft:: Roc:h I • .
. , Casing.Diameter: _ _in. -Casing.Depth . . . ft.' From:1 -•ft.To "I CIft. : :
. . . ... . - .. ;: From:1Z .ft..To''IO.S ft.:. . (sriiv CA c . . - .
:Grout -:: From o .. ft:To: ft• - .. . .1
. : .: Depth Material' Method - From ft..To:_ :ft
-
-Fromc;C_ ft.To:Via• ft. rhea - � c
-�- - -Ge. ��-_: peat;�1T�ai.. From ft..To : ft. f
From:-.. . . ft.To.:. - ft. - . . • : e-
From: ft.To: ft. .: -: : .
- � � From. ft:�To:_;ft-
� Frain!�
Wasik.Production .. • r-.
-Depth:93S ft.. A .S ft.. . . ft. ft. ft- ft:. . .. ft: :
. . . - Yield: : I.. .gpin . gpm : gpm gpm . : gpm
Pm
.. Method of Repair: . :.. . . . ,
- Method of Abandonment:, . . . : .
_
I hereby certify that this well was constructed,repaired;or abandoned according to 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:, � -�
�-�--== � � -Certification#:�+��1'dr P►. Date:. ��la ��. � - ,
.111$tallnd OflPtigutiga gn ilBet e®n
Pump Installation Company: N-
,, 1r-ic : .._ Completion Date .14 : ff -L
i
Pump Depth: SO 0 i ft.; Static Water Level: 5 (J. ft: -
Puny Brand: rt_,0„1 ,r ,5 '5 SGI_1 57-'-i-sr)Pump Size and Rating: hp 5g m
- gpm
: 1.
I hereby certify that;hit.; Was installed and wellhead completed according to 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:. Certification C 6277: ate; . 4/
Revised:January 1,2009 •