GW1--02893_Well Construction - GW1_20240510

MILLct a�fifs'Il'RUCTd®l�RECORD(GW-1) For -- -
Internal Use Only:
1.Well Contractor Information:
I :
Chris King 14.WATER ZONES
Well Contractor Name FROM To DESCRIPTION
2080-A 7 i• 7S7 f. 3 6./ri rl
NC Well Contractor Certification Number ft. ft. I
Aqua Drill, Inc. IS.OUTER CASING(for multi-eased;tvells)OR LINER(if an liable).
• FROM I.TO L`�} DIAMETER"' I "THICKNESSS MATERIAL
Company Name 0 ft• j ft. I d_//`•- ; in. pre 2/ Pi tJ t(..
r 16:INNER CASING OR TUBINGBI( (geothermal)closed-loop)2.Well Construction Permit#• 7 1 l i. {�~-on C FROM TO DIAMETER THICKNESS MATERIAL
List MI applicable zee/(construction permits(Le.,U/C',Conn( State.•V(irinuce,etc.)"'© ft. ft. in.
3.Well Use(cheek well use): ft. ft in
Water •
Supply Well:
17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
O1VIunicipal/Public
R. ft in.
Geothermal(Heating/Cooling Supply) Mtcs i denti al Writer Supply(single)
Industrial/Commercial ft. ft. In.Rasidential Water Supply(shared)
R,
Irrigation 1S.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
MonitoringRecovery ft. •7� ft. �1 J ,���`
Injection Weil: ft• t� ft. T
Aquifer Recharge Groundwater Retnediation ft ft.
Aquifer Storage and RecoveryIn Salinity Barrier 19.SAND/GRAVEL PACK inapplicable)
PROM TO M1iATF.RfAI. EMPi.ACF.DIENTa1E7710D
Aquifer Test �Stormwater Drainage ft. ft.
D
Experimental Tecltnolo y Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer • 20.DRiLLING LOG(attach additional sheets If necessary)
Geothermal(I3eating/Cwlin Return) Other(explain under#21 Remarks) FROM TO DESCRI• ON(color,hardness.son/rnek type.grain size,etc.)
.: .
-q �/ t:J ft• / .- ft l�tc C, l�\l
4.Date Well(s)Completed:/ 2( 2 ! Well ID# (5 ft• /1 -- ft. S i�nrdl , C&
5a.Well Location: ilc n s - f. Give. 6.fzwW).c
7 ft. ft.
Facility/OwnerNeune Facility iDO(if applicable) ft. ft. •
(d d�e; x y j1 1.i c'� OAK Zidq l, y v c C ft. ft. 6 k•b.e 0. 'U....t •• "K Z..",
Physical Adddren-City.and Zip ft. ft. A
(�tJ it F-t9 i�G 21.REMARICS MAY 202`h
County Parcel identification No,(PIN) ` ' ^s.g; r
'`t'
5b.•Latitude and longitude in degrees/mhlutes/seconds or decimal degrees: 't'S"
(if well field.one let/long is sufficient)
22.Certification:
N W 6.240;) I/ e
6.Is(arc)the well(s. ?'crinanent or Temporary Signature of Certified Wcll uactor �� `
[)ate
By signing this Arm,I hardly carlj,that the nr/l(s)was(were)c•onstrvrled In accordance
7.Is this tt repair to an existing well: DYes or o with 154 NCAC 02C,0100 or 15A NCAC D?C.0200 01,11 Construction Standen&and that a
Obis!x trio*,sair,fill ow know)ut•/I construction ImInmulinruand explain the nature of the 1. f
r epal,under 112/rentm/a',sar!an or on the hack r fthiv,form. copy o //r%v rerun!has been provided to the ux/!mrucr.
23.Site diagram or additional well details:
8.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additionai well site details or well
•
construction.only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary,
drilled: i
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfaced
For multiple'wpils list all depNis ifdr.'i/rreat(example-3(rr•290'and 20100') (ff) construction24a. For All Wells:hoSubmit this form within 30 days of completion of well
to the following:
10..Stritic�slevel b water cloly top of casing: 1
Il,tsnt h rrl�c anon be,nor + (1t•) Division of Water Resourcesa,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: - (in.)
24b.For Infection Wells: In addition Ito,sending the form to the address in 24a
12.NGell construction method: /I d�z it above,also submit one copy of this form Within.30 days of completion of well
construction to the following:
(i.e.auger,notary,cable,direct push.etc.)
FOR WATER SUPPLY WELLS ONLY:
Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13e.Yield(;pat) Method of test: 5 j�(�h
1 24c.For Water Supply&Infection Wells: In addition to sending the form to
13b.Disinfection type: [�/ 1� the address(es) above, also submit one copy of this form within 30 days of
Amount: �� �.7` completion of well construction to the I cOunty health department of the county
where constructed.
Form OW-1 North Carolina Department ofEnvironntental 1
Quality-Dicisfon of Water Resources 1 Revised 2-22-201 C

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health, Water Quality Unit
400 W.Market St.,Suite 300,Greensboro,NC 27401
Record of Comet/1=1one Reipak OF AbandonOent of a Weil
Address of Well: 76:en' KcicaLLCt o KrY di C AJr LATITUDE 8
Well Permit Number: Cf-6 I -to lo i-4 it - 0 0 5"b.2 LONGITUDE .
Well Contractor Company: /400 M Prz; i i Completion Date: 9 -g C-2 Li
Total Well Depth: goc ft. Well Yield: 3 gpm Static Water Level: 6 6 ft.
Outer Cash ,Material: 5 Dr& 2 I Pi ti, C ' Formation Log
Casing Diameter:6 6-I in. Casing Depth; /2 I ft. Depth Description
From: 0 ft.To:1 5- ft. 2 c ( )19 y
Inner Casing • Material: From: / c ft.To:)1 5 ft.
Casing Diameter: _in. Casing Depth: ft. From:)/$- ft. To:1iC ft. )3 I 0 e 6-fziAN
From: ft. To: ; fi.
Grout From: ft.To: , ft.
Depth Material Method From: ft. To: ; ft,
From.: 0 ft. To: 20 ft. C erneiv-i /riu C/C From: . ft. To: __ ft
From: ft.To: ft., From: _ft. To: ft.
From: ft. To: ft. From: :ft. To: ' ft.
_ ...
Water Production Zones
Depth: 75:5-ft. ft. ft. ft. _ tft. _ f.
__ . ft.
Yield: .3_.Wm ___gpm gprn _.gpm ___gpm '._____gPm gpm
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.
,. ;1Well Contractor:..e. ___/ . State Number:2(SO -M Date: c-f-,76 7 02 (1
Rrcomil of Pump Enstalliledorro I .
Pump Installation Company: 4
.49
'IL -lo-c Completion Date:Ar7/67/fry
Pump Depth: ...00-0 ft. Static Water Level: efO ft.
i i/n
Pump Brand: C-fruedP0 s ,..6.--s,,,..‘r- 6/..ra Pump Size and Rating: ';/ a .hp_.. S. „.._gpm
I hereby certify that this pump wa installed and wellhead completed according to the Guilford County Well
Rules in effect 011 te and t at a copy of tl is recor has bee provided to the well owner.
Well Contractor: 'ate Nuinber: (2y04r-1,if- Date:
• i '
1
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