GW1-2022-05600_Well Construction - GW1_20220614

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only: _
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A eft. rt 5 -t 19t t
ft. ft
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased iwells)OR LINER tf a licable
Aqua Drill, Inc. FROM I TO 1 DIAMETER THICKNESS I MATERIAL
ft. . 0 ft in.
Company Name 0 �' -�I I , ,C
ram' 16.INNER CASING OR TUBING(geothermal closed-log
2.Well Construction Permit#:tri 74,C) FROM TO DIAMETER THICKNESS 11fATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance•etc) ft. ft In.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER ! SLOTSIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft in.
:)Geothermal(Heating/Cooling Supply) oiesidcritial Water Supply(single) g g in
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
7-3Irri ti0n FROM TO MATERIAL EMPLACEMF,NTMETHOD&AMOUNT
Non-Water Supply Well: ft. ft ��/C
.'lMonitaring Recovery ft. tt
Injection Well:
' � ft ft.Aquifer Recharge Groundwater on!Aquifer Storage and Recovery I_, Salinity arr Bier 19.SAND/GRAVEL PACK if a licable
__i FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �+-Stormwater Drainage ft. ft.
:Experimental Technology oSubsidenceControl ft. ft.
"Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal(HcatingiCooling Return) ; Other(ex lain under#21 Remarks) FROM C TO DESCRIPTION(caloq hardness soil/rock a rain s' etc TA
)
�J
4.Date Well(s)Completed:5 Well ID#�f) 1 ft. t `' ft 5 l��i Q ,C jv`d
5a.Well Location: ft• S!�J^-tt � u C 1
ft ft.
C Facility/o
wnerName f t Facility IDD4(ifapplicable) ft. ft.
J [vt)1Z��f tr 5cko d�C lI E Ero11��Rd ft. ft r
Ph cal Address City,an Zip l�/>C' �7 Y Q k. ft.
ILI
21.REMARKSJL X r.VL'_
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lat/long is sufficient) 22.Certificat' n +�
a
6.Is(are)the well(s) Permanent or DTemporary Signature of Certified Well Contractor Date
1� By signing this form,1 hereby certify that,the rvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or`E§No with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information and erplain the nature of the copy of this record has been provided to the well owner.
repair under#21 rent•/section or on the back-of this form.
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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
p r 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 ifdif/erent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,If water level is above casing, „U t,
l�e/�' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
12.Well construction method: A j- t above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
� I
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 (T Amount: I�. completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W.Market St.,Suite 300, Greensboro,NC 27401
Record of Construction, Repair, or Abandonment of a Well
Address of Well:j 3© o it 1,c,rs F 5"C!,�d 11.E C� en ba�6LATITUDE 3—
WeII Permit Number: (,���� 1� -c3 7a'O ONOTUDE
WeII Contractor Company: + ,�nC_ Completion Date:
Total Well Depth: ft. Well Yield: _gpm Static Water Level: ft.
Outer Casing AM—aterial: S 2 �! �,0I-C Formation Log
Casing Diameter: in.in. Casing Depth;Z2 Q ft. Depth Des ription.
From: O ft. To: 1K
Inner Casing Material• From: S ft. To:
Casing Diameter: in. Casing Depth: ft. From:il, ft. To:3,Z:L ft��61Z4111
From: ft. To: 'ft.
Grout From: ft.
Depth Material Method From: ft.
From:�ft.To:_)-6 ft. c'.� TdC From: ft.To:—ft.
From: ft To.-_ft. From: ft. To: ft.
From: ft.To ft. From: ft. To: ft.
Water Production Tones
Depth: 9q6 ft, ft. ft. ft. ft. ft. ft.
Yield: gpm gpm
lafim 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.
Well Contractor: - o Certification#: 0 Off-?IV Date:
Record of Pump Installation
Pump Installation Company: Com letion Date: (ll ©�ul
Pump Depth: ft. Static Water Level: ST ft.
Pump Brand: `�+-��`a� 'k a PiDSD_�pump Size and Rating: : hp gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on thi d e and at a cfopy of is ecord has been provided to the we]I owner.
WeII Contractor: 2 / -\ Certification Date:
Revised:January 1,2009