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Home My WebLink AboutGW1--02765_Well Construction - GW1_20240506 WELL CONSI'aRUCT ON RECORD f GW-1) • For Internal Use Only: • • 1.Well Contractor.informationo Chris King . . . . 14.WATER"ZONES Well Contractor Name R ... FROM . '. TO _":. . . _.DESCRIPTION ' ' 2U80-A ' NC WellContractor Certification Number • 1 ft 1 tt, I . :lout if,.. Aqua.Drill, Inc: • • - 1S.-OUTERCASING'(formilli-caged wells)OR LINER(if all licable)': - �Company Name ': � . .. • FROMTO' DIAMETER THICKNESS. MATERIAL • • fit fit.' !/q in. Z P 2..Well Construction Permit#. 16.INNER CASING OR TUBING(geothermal closed-loop) ' . 3'-Q-•� •wC�!iv I C. Ov t))c3 FROM- - TO'- •DIAMETER• .-- THICKNESS- . . MATERIAL . ' . List'allappltaahle ire(!eintsInIction pennrts(l e:UIL Count, State;Variance,etc:) R.. - R. '' is " 3:Well Use(check we11 use):. _..- ft:: fit. 1a Water Supply Well: • • 17.SCREEN. - _. ' .. . _ - Agricultural • OMuaicipalll?ublic . - FROM.t ' To .,-. • :.T In— ' SLOT SIZE .. THICKNESS -MATERIAL. Geothermal Hcatin Coolin Su l esidential WatcrSu 1 it. . :tt. to. � � g PP y) PP y(single) - . Industrial/Commercial DRcsidentia1 Water Supply.(shared) • iB.GROUT Irrigation • : ., . . FROM. TO ' MATERIAL .- 'EMPLACEMENT METHOD&AMOUNT. • Ng fiftt (fitt..-(G'w1 Yht' �"� /� �Monitoring. . Recodc !Injection.Wel •l; • • Aquifer Recharge Graundwafer.Remediation Aquifer Storage and RecoveSAND/GRAVEL D ft • ry • .Salinity Barrier -. TO.' . • (i AT RIAL. Aquifer Test •DStormwater Drainage fit FROM ' Experimental Technology Subsidence Control ' ft R. fit , Geothermal(Closed Loop)" Tracer .20:DRILLING LOG(attach additional sheets If necessa Geothermal(Heating/coolingReturii) iOther(explainunder#2IiRemarks) FRUaf To..` ' ' DESCniPT1oN(color,hardn y). .-: - ess,sa Wrock type;Morn she,Me.) Weil ID# . . _ :i ft.' d •ft.: c� 4.Date Wel(s)Completed "I 5�, 1� � _i oh • Sa..Wei1 Location: d�`o c K � 'i"�'u ." CO . t. � L. 13i � lta) } tt:_ ... . . . tt: Facility/Owns;Namc Facility ID#(ifapplienbie) 4 • fit. -- -� - f'ii$ l t9K_"IZid'i-e. - zd S�, , ft . �. ca►v�Fzl'iclt'�. tI. ` PPhysical Addreycs:Ciii.and Zip•' . lea c C.-p' 73 s ( ..ft. it._ 1 ' . wi AY . .. 6LI h 1 F0:2c1 : • 21.REIVIAR cS _ County r Parcel identification No(PIN) D h.C.. Sb.Latitude and.longitude In d g •egrees/minufes/seconds or decimal degrees' • (if well field,one laiilong is sufficient) 32.Ceriitie ion: .. ' .. N W 6.Is(are)the wcll(s t►. Permanent or OTemporary . Sianaturc 01Ccnificd Well Contractor ' - Uatc./ram Z 7,Is this a repair it to an existingwell: By shining this,trrrnt.I.herehr eerih•that the nv/I(s)was,(were)c•anstnicted In accordance- DYes• or %'No arch 15A'NGAC 02C.0100 or IS4 NCAC 02C 0200 Well.Can!,sa.ilon Standards and that a . (phis Is a rdtair,flit oat£noi,n well rcinStru rims m ini niatinn and opiate the nalari•of the 'eaj?i r flh%r rxrrird has(wen proridcd to Nre;ne!!mi ner. sepal,antler 1121 rc marks sertlon it,.an the hack ofthisflaw; . 23 Site-diagram or additional hell 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 constructign,.only 1 OW-1 is needed, Indicate TOTAL NUMBER of wells ' constructuin details,•You may also attach•additional a t'' drilled: page if necessary. SUBMITTAL INSTRUCTIONS *7 9.Total well depth beloand surface: tV.l � (R:) 24a.For multiple:rolls list ell depths'fdperent(example-3@- 00'and 2(p1100') cons rFOrust All theWe following 10.Static water level below top of casing: tJ (ft.)• 1 Ifuwmrlevel is irhae casing."Sc"� Division of Water Resources,information Processing Unit, 1617 Mail Service Center,Raleigh,NC 276994617 i 1.Borehole diameter: (in.) 24b.For Infection Wells: in addition to sending the form to the address•in 24a 12.Weil construction method: j . above;also submit one copy of this form within 30 days of completion of well (i.e.auger,cola,) cable,direct Push.etc,) , . construction to the following: FOR CJIsTB12 SITPPh`e'•WELtiS ONLY: Division of Water•Resources;Underground Injection Control Program, 1636 Mail:Service Center,Raleigh,NC 27699-1636 • 13a.Yield(gpm) '. )57 Method of test: 5 , 24c.For Water Supph &-ingestion Wells: In addition to Sending.the form to l�ja� the address(es) above, also submit one;copy of this form within 30 days of .13b.Disinfection type 1-I rig- Amount: 1 4. . ;el�' r �,.; completion of well construction to the county health department of the county Where constructed. Form GW-I North Carnlinn rlannw...:...,-.c....:�___-_._.et-_.. ... .. ...... - GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH Division of Environmeiital Health, Water Quality Unit 40.0 W.Market St.;Saute 300,Greensboro,NC 27401 Address -f Well:9/ l� . �`ll�� 0 � Wen �' �'' i� /� 9• �.°'f or l6 LATITUDE 5---- Well Pei it Number: �3 -t?• ,vi4 - 0®n54 LONGITUDE Well Con�actor Company; � --- ^ : Completion Date:- .j$-- !.-�. Tota Well Depth: ft• Well Yield: s -�-_gpm Static Water Level: 30 Putter fat.nxs Material:51)..1.12 ---- ft: i � Forhaation Log Casing Di titer /�- -.L in. Casing Depth: ft. . Depth �n'�ex'has{r;�g From: 0` ft.To: 6. . ft: . Description Material a:� Casing Diameter: From: _ft;To.. in. .Casing Depth: ft. From 3Z ft 5� fin•®tat Froth: ft.To:. ft. _ From: ft.To: _ ft; From: 0 pepth Material Method From: ft,To: ft. From: ft:To: ft. , Froni: ft.To• ft. From:Tft. To: fft. From;. . . ft.'Toi $, From: ft. To - . ft. Depth: 5"� Water Produed$oU Zunis. p ) S-ft. ft. ft. ft• Yield: ��gpm . . �. gpm gpm gpm ft: ft. J' gpm gpm gpm Method of Repair: Method of 4bandoinnent 7 I Hereby certify that this well was constructed,repaired,or abandoned Rules in. eff ct on thus date and that a copyofthis record has been provided tot a well o Guilfordr County Well : p Well Contractor: . State Number: 0 ( 1 Date: c- - 9 Pump Installation Company: �yw; I.\ _ Completion Date: _d A Pump Deptli: ft. Static Water Level: 5b Puna B ft' p ran - ni, 1 C� fl�'� Pump Size and Rating: hp I hereby cert� that this =----�gpm fy pump was installed and wellhead completed according to the Guilford County Well Rules in effect on this date an that a copy f this record has been provided to the well owner. { Well Contractor: . State Number.'-.Date:_147.WZy..