GW1--06232_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ; t .....T
Chris King 14.WATER ZONES,
Well Contractor Name FROM TO DESCRIPTION
2080-A I GJoft. iq t rt. aZ 0 cr.)P i i4
NC Well Contractor Certification Number A 5`�'ft' 5 1 ff. Si 6-P Pi("1
IS.OUTER CASING(for multi;eased•wells)OR LINER of ap Hcable)
Aqua Drill,Ina. FROM TO DIAMETER THICKNESS MATERIAL
Company Name C) ft. G( IL(ft f/�4 in. 5 or r a) i Jt :
_^p Ai
�f 16.INNER'CASING OR TUBING(geothermal•closed-loop).
2.Well Construction Permit#::12 Li —0 7 - )f V)-1 it—C3°6 t,S-- FROM TO DIAMETER THICKNESS MATERIAL •
List all applicable well construction permits(i.e.UIC,County:State.Variance.etc.) ft ft. in.
3.Well Use(check well use): ft it in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural °Municipal/Public ft ft. in,
Geothermal(Heating/Cooling Supply) Ekesidential Water Supply(single) -i, IL in.
Industrial/Commercial I�Residential Water Supply(shared) 18.GROAT
Irrigation FROMTO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0• 0 n• �°�'p.p L f ��
Monitoring R. ft
Injection Well:
Aquifer Recharge (�+Groundwater Remediation ft. ft.
19.SAND/GRAVEL PACK Of applicable)_
Aquifer Storage and Recovery
Aquifer Test •
°Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°5tormwatu r Drainage ft. R.
Experimental Technology Subsidence Control ft. ft. .
0
Geothermal(Closed Loop) �ITracer 20.DRILLINGLOG.(allachadditionalsheetsifnecessary)._
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM. TO® • ft- 5- ft- DESCRIPTION(color,hardness,son/reek type,gain size,etc.)
5�l+ G
4.Date Well(s)Completed:JO '7' 1 Lf Well iD# 5 R' l5 ft• 5oreid. IZock
Se.Well Location: 5- ft. 165 ft "lives 6-7440,Imo.
ft. ft.
Facility/Owner Name Facility ION(if applicable) ft. R. E c ^`•-i _ ' •,
LV' --t
ft. ft.
39./6 14IAIMJAD ire a d 6,-ize Si9ead W.� ft. rt. OCT J i �0«
Physical Addnss.City,and Zip
6``. I iFe1 Z1.TtEMARKS. _ i
County Parcel identification No.(PIN) - . fl,`;' ..7,-.,±•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) 22.Certitle Hon: 1
N W el°2 l 176 '- 7'' 1
6.Is(are)the well(s) ,' rmanent or .DTemporary Signature of Corti ucd Well Contractor • Date
Bp signing this fine,I hereby cer0,6,that the stairs)was(were)constr uctal in accordance
7.Is this a repair to an existing well: DYes or Orzio with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standard?and that a
((this Lea repair,fill out known well construction b fbrmatinn and explain the nature oldie ropy of this record has been provided to the well muter.
repair under 021 remarks section or on the bark ofthLaa font. 23.Site diagram or additional well 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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3@200'and 20.100') construction to the following:
• 10.Static water level below top of easing: (ft) Division of Water Resources,information Processing Unit,
If Inter level is above casing,use"+•• 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 63 (in.) `` 24b.For injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: �� dI�1� 9 above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 100 Method of test: 5 n elk 4 24c.For Water Supply at inlection Wells: In addition to sending the form to
T/� �t -the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: /4/ /-f Amount: /6 -0-i-- completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource Revised 2-22-2016
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GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W.Market St.,Suite 300, Greensboro,NC 27461
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Record of Construction, Repair, or Abandonment of a Well
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Address of Well: 3 9/6 Af/aman a Tel LATITUDE 3
Well Permit Number: 214- a1-NA) tt 2- oo 6 9s LONGITUDE
` Well Contractor Company: qua Drr7/ c Completion Date: /0/67/2 q
Total Well Depth: 26 c ft. Well Yield: /00 gpm Static Water Level: 30 ft.
Outer Casing Material: .S9 g z 1 ?.v.c Formation Log
Casing Diameter: 6 141 in. Casing Depth: yy ft. Depth Description
From: 0 ft. To: S ft. Sa
Inner Casing Material: From: s ft.To: 2r ft.. Sane ?ocic
Casing Diameter: in. Casing Depth: ft. From:2f ft. To:26r ft. rive E-, ,*e
From: ft.To: ft.
Grout From: ft.To: ' ft.
Depth Material Method From: ft. To: ft.
From: 0 ft.To: Zo ft. CHrii,- "keit* From: ft.To: ' ft.
From: ft.To: ft. • From: ft. To: . ft.
From: ft.To: ft. From: ft.To: ft.
Water Production Zones
Depth: /9/ ft. Zsa ft. ft. ft. ft. ft. ft.
Yield: Zo gpm St) gpm gpm 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 dat and that a copy of this record has been provided to the well owner..
Welt Contractor: f.z.:,...
Certification#: Zo a-A Date: Ay 7/?II
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Record of Pump Installation I .
Pump Installation Company: Acuc Drill :rn r. . ' Completion Date: /0/ lb/Z'/
Pump Depth: 2 1 0 ft. Static Water Level: 4/011; ft.
Pump Brand: C Trern d,Co S Pump Size and Rating: 5 .hp 35 gpm
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I hereby certify that this pump 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:,4,o7r�4rieC5 f?..e--- Certification#: Z677- C Date: /0/ 1triz ti
Revised:January 1,2009
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