GW1--02767_Well Construction - GW1_20240506

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CW1-IL dL.¢Mal S'Il'RUCTgON JICECO?',1;: aVV 1. i
For•titernul Use Only:- ; '
1.Well Contractor Information:
Chris King . . :" . . ;
Well(ontrgctorNatnc. 14..WATERZONES I
FROM: TO. -
2OSO-A
NC Well(761tadorCenipCition Number R. I. t
Aqua;Drill,torCe
15.OUTER CASING(for tduttleased tvellis)OR LINER(itupi;lleraplc).'- •FROM• To• DIAMETER . . TIHCIN1FSs' . .MATERIAL .Company Name " (t, I
• 0••• I.
CI ` .!w•I //q ..In Sbra i• •P1-✓9 C
• 2. ..gp .Te•' .Construction.Permit#:-0. ' . �o �.t•��/2 .16.INNER CASING OR TUBING( dosed-too e-
L. all npp/uah/e well rn lJo,,permits•(r,e.OK Cohn, .State.Var/ant a ate) ``�. FROM f' TO . • '_DIAMETER THICKNESS •. .MATERIAL.. •-: •
• 3:.Well Use(check well•use): . •• -
� •, io.
•
fL' • .'•�. i In.
• Water Welk
.. . • • ]ZSCREEN..
1�AgnCUltu l DiV11DI1clpaVPub11C •• FROM ' TO DIAMETER i. SIOTSI� .. :TRICKINESS'
:MATERIAL'''.
Gcothcniial(Hcating/Coolin Su 1 R• ft in. .
$ PP Y) Itesidcngal WatcrSupnly(singlc).
>�IindustriallComntcrcial I• ' ft. R
Rcsidcotial Watch Supply(shared).
•IS GROUT'. '.. :• •":
N Im aiioti u I :. •• . • • ' FROM.. . •I TO. • - •I MATERIAL-• : 'EMPLACEMENT METHOD&AMOUNT
. . pP.Y •gNMonitoring Recov-" . •
Injection"Well: �" f O h, .
. G
iwi Aquifer Recharge .tr. R..
• � roundwater Remediation •
,$.Aquifer Stofite and-Recov •' Salmily_Bamcr. '19 SAND/GRAVELPACK(Ifmipllcabte) ' .. .. .
• `FROM TO ' •tAquifor.Test'. ft.• MATERIAL. • ' . ' . E4IPLACEi1F-RTMERIOO "
E3Stormwater Drainage: . • • R.
1!�I I xperimental Technology, • :OSubsidence Control
.
1R Geothenral.(Closed Loop) T • • . . . .
. :20.
.R. R
.i Geothennaf(Heatirig/Coolmg,Retum) . Other ei lain tinder•i12I Remarks)_ o DRILLING LOG(attachadditional sheets if n )
( p
e
d R' ��: R
DESCRIPTION(arotar,andarsa wD/radc Npc,solo size;ei�).
•
•
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4 Date Wells)Completed q_2 7 '.Well ID#. • • ci .ft•. •L'
5a.:Well l ovation
i• ��is
G
n.: .�� Tiz•19•n71,-fie..
"`J455a re,• • 7Z(b-I'rlIZA .1 oi- fL' . R• • •
Facility/(wnr'slim • • • , •
': • 574.12.('--I • te4,.,61,„1 ::.r2...d.•. :6,,,,e,„-sb.ucility ID0(ifappltcabrc) " ' R. R' ' '. •
.
Physical Addn.s;City,and Zip '
;4., j A:Y. .G eG2'4
J*J I pol,a '.!"� 1" 21 REMARI{g R• --
County
• . • -Parcel Idtindfication No,(PIN)•-
•.: 5b:Latitude and longitude an•degrees/minutesfscconds or decimal deg_reel: • • 'Gf well field am.lavlong is sufficient)• •
22:Certification:
it
VV
6 Is(are)the iVcll s •,
O ermanent or DTetnporary. Signature ofCcru red Well Contractor.
• •i' � Date
7 is this tf repair to an C7ilstln well: �� B•r x w/4 ibix lbrnr,I herein semi tlrni Ire ue//(c)uc c(hare),eanstructed in ac4nrrlaace
g Dyes dr.iT�io IOW,15A NCAC 02C.0100 or 15A NCAC 02C 10200 Hell Constntction Standouts and dada
Ifdds h a rcpmr•/ill out/unit,,hx l/c nminrrNon lr frrnraRnn rainerplaln rile minis c jihe' • ea,tkr:of:ililx ice onl bar heea prat Ided ru the.itxllmincr.
roar•under 621 e nmeL,,u•Ian qr on the bath r fII,!,Jann: - ' -
FL Far Gco robe/DPT or Closed-Loop Geothermal Wells having the same Sm y I s he boa of this page toot detente.
P 23
constructton;only l OW-1 is needed,-Indicate TOTAL NUMBER ofwel s You di od ' '• '
dolled:
cgnstnt iron dtilails._You may also.atto h tidditionanta al well sue details of well
pages if necessary.
•9;Total,well depth halo*land surface: 2. 4,L 5UBMITTA;I,INSTRUCTIONS
Fornad:Jple wells Ihrcill depths lfdi//errnt(Csamp/n 30 ')O mtd.2tm100•l ". (R) 24a.. For All Wells: Submit this form within 30 days-.Of completion of.well
construction tothe following:
10Static sestet^leycl bdoty top of casing: I
10:St r/list a ea le level
ase• ' (ft•) Division of.Water Resources,Information Phocessing Unit,. '- -
irtiI I.-Borehole diameter: 1617 Mail Service Center,Raleigh,NC 27699=1617
On.).
240:For Inieedon Wel•l•:• In addition to sending the foam'to the address in 24a
`Veil construction method;—/JJ_J . . t . above also submit one copy of this form within 30 days of completion of well
12
(I.e.nugdr.manly,ruble;.direct push;dc.j wnstnrction.to the following
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FOR(V�i�i tuy2 StlppLl WELLS t):dT.y: Division of Water Resources,Underground Injection Control Program;
'1 636 Mall Service Center,Raleigh,NC 27699-1036
13a.1'ictii(apnr) •• M•ethod of taste } _
•
24c.FF�Wat.. SnDD1.&:Iniection-Wells: In addition to sending the form to
13b 131sltiiccficn }pe.. a B_ the addresses) above,'also submit-one copy 1 of this form within:30 days of
,tea, Amounts 2 1, completion of well construction to the cou ty1health department of the county
C where constructed,
Funs OW-1 North Carolina Department Of avironinental Quality-Division of Water Resources
Revised 2-22-2016

- GUILFORD COUNTY DBPARTMENT.:OF.PUBLIC HEALTH: : " . :: • : :
:: Division.ofEnyironitrentalIealtti,:Water Q" ali' Unit: .400 W Market St.,Suite•300, •Greensboro NC.27401 : ." _
_ _ Record of:Construction, Repair,:or Abandonment_of.a:Well..: :: :: .
Address of Well: ra.r,i,1 zei Y4r�e >,a� : • " . .. . .. .
--.SC' �Zo LATITUDE 3
Well Permit Number••• - 10-.
: - IZ.-OOLl 16 . : LONti17UDE
" : •�:.Well.Contractor.Company: • . . .
"Aqua Dnll; Inc •Total Well Depth."o22$ ft: Well Yield; .2 0- m Static Water L n Date � �� � �/
• : " � gP r Level. :�V. . -�:ft....". : ::.. .. ..
Outer Casing.' . Material: Dj,? 1 ID �, " . .
Forma0on Log •
: :Casing Diaineter:4A.1 in. Casing Depth:' .4 c[ ._ ft
•
• Depth Description
Liner Casing : Material: . • c .
•. . From , ft To. S'ft.': :A 10,e. 6a0, ,. e .Casing Dlatneter:
• in •Casing Depth: :Fria*.
". : From • : •ft..To •:ft; "
- :.: :Grout : ." : : " .Front ft.To ft:. .: :
Depth: Material. : • •
From: oft AO t, .
M
. . .. ••Tti o'efC. •: .. From •_ :ft.TO:: .:... it;:" : "•.
From:_ft..Tot. . ft.
•
_ _ From :fl,To .:{};: .. .. .
From•. :ft:.To ft. .....H.: : :"From, - : • .. :" .
• � � ""eft.To. ;.ft.• • .. _
�:ft.. : - W afar Production Zone's•..
•Yield :�o.gpm• :�= gpm � " . : at.••• . ... . .
. � att. �ft. .
limit gpm: gpm . gpni gpm -
:Method of Repair. : ".
:"Method of Abandonment:..: : .
t
I hereby cerhf�r ... " .. .•
. . . •
., •, .
that:this well was constructed,repaired,or abandoned according to the.Guilford:County.Well :"." . :
Rules in effect on•this date andSthat a copy of this•record has been provided to the well owner. -•
Well;Contractor. _ .. . . 280-A•
. . .•" Certification.#r. 0 ,: . R4 ...... .
. .
oat-. .
cord of�Pump Insta ion. .
Pump Installation Company: `' ".:lt�-i j i .
. . " Completion Date P/ ..
• Pump.Depth: " "t.S b. :-, ft. Static Water Level: ".5�. ft..
:Patti Brand:: .• • '.
f (f)i'cr .•.PIO.00 5F.':..:: :. lie,
Pump Size and Rating • • _. hp•. 1� •gpm - ,..
• � I hereby certify:that this . .. " .pump was installed and wellhead completed according to the Guilford County Well:
• Rules in effect on ' � � "
.'and at a cop of ' record has been provided to the well owner.
Well Contractor: . .. . "� . � •
• .• Certification# ���.;- Date: �� p/.� Zy: .. -
Revised:January 1,2009