GW1--02766_Well Construction - GW1_20240506

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a04:l.If..,.LUNS'&'YtUCtION RECORD(Gyil-1): •. •' • For internal Use Only,
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1.Well Contractor Informationd ' • • .
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" .. ,Chris Kmg;_•" �'' - . ".7-7.
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Well . . .
C U
Ro ATER ZONES
.. . . . 755' 7 tl: '3..l It l wl
VCWcIICo.. -: •Cenifico-,. •Number
Aqua Drill;•Inc • • • • 1S•OUTER CASING(for Multi.cMed'Williz)OR LINER Of ap&able),
• Company Namc • '
TO -DIAMETER'
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T1IiCKNFS3 MATERIAL
r�l, 16 INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#qC•7 f. f frJ) p --06 Q -FROM ' TO. _.. "List'all appliceal!e ord conatractfon pern,kc.(1.e..UIC Counts State.Variance ere• ' . ft. g; 'DIAMETER r .THICKAFSS ' . 'MATERIAL
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3:Well Dee(check well use) . "
- R. • D
water Supply Well:-
. 17.SCREEN. ..
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titer.Situral ' -
FROM TO DIAMETER SLOT SIZE - ••• . •. .":•. • MATERIAL'
. �MuntctpaUPublic " • r�" '.' "R 'in.:: .
Geothermal(Heatmg/Cooimg Supply) _, tcstdential Water Supply{single) •
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fi tl:• In;
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industrta/Conimcrcial . :�Residcatial W acrSupplysha>cd) 1&GROUTr - ' _ -irrigation. . • ' ' FRON_ ° . MATERIAL• EMPLACEMENT• Non-WaterSnpplyWe11 0 � R. celyl:PtlT �Lic :' '. g _DRccovcty. -; .. .
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Injection Wells
Aquifer Recharge Groundwater Remed,ation " " "" ff• ft
Aquifer Storage and Recovery 0$ahnity Bamer •19 AND/GRAVEL PACK(IfappIIcable)- "�." .". " •
Aquifer Test. MA EatPLAEEPIEl1TntETRol1
FROM TO.- MATERIAL-..
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. . E3Stolmwater Drainage " ° .. . :If.• . '•fit .
Experimental Technology QSubsidencc Control .. . .ti:• . •'
Geothermal(Closed Loop) Tracer. . ' ": • . •. i.. ' ' •,
O. : 20.DRILLING LOG(attach addittonal'eheets if aaessary Geothermal(Heating/Cooling•Return) f Other(explain under#2!Remarks) room. To ottscRl oN(rotor,hardness wNmetc e�pe amtn size etc)
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4 Date Wells)Completed;
Y. e�' �_�.Well'nip _ • � it �r�..t1 S
5a.Well Location: •
rt.
115`'::rt: SSdr' i: RWniltle.
• "":Facility'(hv,ic ^flmc• � ".. : �
ff
FaciliiyID$(if applicnblc). : • ff ILL ,-m. ••-,,.Q L i
• ?6S•� Kye ' -�--:Olt e. . a� y
• C. .. . 1�GP" "w��"
Physical Addn s'City and Ziji :"
.,�.: "�tY • • � .MAY
(-s_t L Fo t .: : ' ' • 21.REMARICS -- 1 ; li,of is r t,raG-c� 1;>Ii..
County. '
Parcelldenufication No(PIN)'
I CtW,lu:SLJv -
Sb:Latitude-and longitudc.indegrees/minutes/seconds or decimal degrees:'.. _ •(ifwellheld one IatiIong is suffcient)
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22:Certification ;. "
6-IS(are)thetveli(s crn,anent" :Or. Temporary " SignatureofCon,fictl Wc1I. tractor ,'. " " "
7•Is this`a ren2;p to a• •.• ••a well: .. -B,i signing ihir•torn,,I heirhr a crtlij t/rat I/te.itull(s)a ge•(were)c nnwnn ted"h,au.•ardance " " •"
g QYes or 'o ." • 'aiih,75A NCAC.02C.0100.or ISri NCAC 02C:0200 lit!!Consincellan SlendariLL'and t
.Ifihcr is a ,.pair,fill bm knauyt"iitllrotcrtrui ilon�trawlim and erplain'sie,iaitire c jdie t Ogr of t/tis'trill hue ken pri,rided to the stall ituner.''
Tcpafr,tnt/ei+(2Premarks eeclinnor on rim hue*oftidsj nn• ' _ • • ' '. " '
but n'
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, . •" or'additional ell d tails
S For Geoprobe/DPT or.Closed Loop Geothermal Wells having the same • S may use the back of ths age'to provide additional Well site details or.Well. .""
• ''eonstructiy wall/1 GW-I is.needed: Indicate TOTAL NUMBER of wells. etails: You may also attach addition
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You
constriction d
al pages,fnccessary;
9 Total eeR depth belowlandstlrface: • • TT••LUST . •
���,•
�" NS
/2 SUBYII R � .•
•Tor notlilplr hill t h bel tp l andiffirria tcran,pfc 3r it290 an42(d;)00h.
(fit) 24a. tiuC Alt Neils: Submit this form within 30 days of completion of well,
10 $ta>;e writer level below.tap of casing •� Q
construction to the following
110 St tic is oh l e caring est o : -
(ft•) Division of Water RestCwrces,information•Processing Unit,
" 11 Borehole diameter _"� (in•) _ "
"1617 Mali Service Center;Raleigh,NG 2Z699=1b17
- -24b.For:Infection Walk: hi addition to sending the foam to the address in 24a
I2 Well construction method: e
/T! _ l o �.•
above,also Submit one:Copy of this form 'within 30 days:of completion of-well ..
(i...Huger;rattily cubic,Jim ct push.etc.) .: construction to the'followin . ' •
FOR!iVA;)u2R 5hi'PL1 WELLS O\Y• •- _"• tvice 'Undergroundte ,Injection 7 Control Program,• .
•.13a.1'leld(�pnt) � Method �• " " . . nter,?Raleigh;l\C 27699 T636 •:. '
Division of Water Reso
' �;.". ' 'of test • " [. �
1636 Mall Service Ce
24c.For Water Sunolv•$t Tnrectaon Wells: In addition to sending the form to" " "13b.Dlsln:cctaon.type• r 7•l I Amount( fZ
the.•addresses) above,:also submit one copy•of this form•within 30 days of .
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" • ' •the
completion of led. construction to county health depa,vnent•:of the county where constructed �'.
Ptiriu fiW 1 North;Carolinti D •
epartmeat of Environmental Quality Division ofWater Resources
Revised 2-22.2016
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GUILFORD COUNTY.DEPARTMENT OF PUBLIC HEALTH
Division.of Environmental Health,Water Quality Unit
- 400 W.MarhetSt:,Suite 300,Greensboro,NC 27401
IRc c©I°cd3 of COrrostp0060© Q00&loll.,o Qbapdoiiiii Ent
Address of Well: 76A6 :K< .Cf :06 Kra:d c-:„Air LATITUDE
Well Permit Number: '6 I " N i4/z.70 O:S o 2
Well Contractor Company: /400 114 ppz; I)
Completion
. Date a
To#ai fNell Depth: .8 6. .
y t-I
5 - ft. Well:Yield: .3 •.
. . . . . gPm static.UVateT.Level 6
Gutter Pasting Material S D d`z I . . I i v,.C
r�t � ; �'®smam®�a Log
g Diameter: /�/ _an.. Casing Depth:. /2/: . ft, . .
-���. Description
Kama!��isAm . ` Froni:__ft'To f@.
g llJ[taterial: 15 Z t C' )
Casin Di p o:J/ 5 'w..
g ameter ... � Frown:a.�ft•T :S ft.. �1z p�c��'. .: :
in. Casing Depth fl. From )/ "-- ft.To Old `ft. -
- � �.a� e��.-��iz�-iiv ire
From.. at To: . . : :ft. .. . •
tGrout . From ft:To:. : ft..
DePth Material . Method Frain: r. To:. £t:
rmm•. C7:ft.To: 10 ft
C ernm./v-1 /nu c/iC. Rrom. ft.'Fa• ..ft.
From: ft..To. ft.
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:� �ft.To°� : �ft.
From:.: Frotai
ft.To: fit. From: ft.
. Water Productions Zones
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epth "57ft 7s .. • f}:.: . ft: .. .
Yield:. .-:, gpm gpm
.. . in . .. . ft:. tt... ft.
Sp
Method ofRe air: .
Method of Abandonffient:
I hereby certify that this well*as constructed,repaired,or abandoned according to the Guilford County Well
Rules in effect on this date and that a c
� opy ofthis record has been provided to the well owner.
Well Contractor � - - - ,
..- 1 4-4 - State:Nuinber: 2051.6 14 'Date: 9'2
F®rl'7 ©g Puratip gni allIl toon
Pump Installation Coin ati
P Y Ulf - `/ c, :..
_. Completion Date: .Vaiie y... .
Pumpep
Depth: ® . Static.Water Level: ft.
. . .. ft
Pump Brand: e-rremd ips Puny ) I Size and Rating: 1 02 hp gpm
I hereby certify that his pump wa installed and Wellhead completed according to the Guilford County Well
Rules in effect on his to and t at a copy of tl is recor has bee provided to the well owner.
Well Contractor:. t .
Number: 090�-� Dade: