GW1-2022-07146_Well Construction - GW1_20220804

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES j
Well Contractor Name FROM TO DESCRIPTION
2080-A I'76 fL f 7 1 ft1 ,26 61'P 101
NC Well Contractor CetlificationNumber ,15:OUTERCASING formul&cased'Wells UR`LINER"rfa Gcable .': -
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS I MATERIAL
Company Name ft. 1 t—"L `C/ I m. 51 it L'1 1 A,V➢J
IN
i > 1 1 HI
6cNERCASINGURTUBING eotliermatclosedloo C•
2-Well Construction Permit#:�)�_ 1 �-✓ t'1 tZ-7-)D 7n FROM TO - DIAMETER : TCENESS MATERIAL
List all applicable well construction permits C.e.UIG County,State,Variance,etc.) fL ft
3.Well Use(checkwell use): ft. ft in.
-47:SCREEN`
Water Supply Well:
. ;. (", :•.i
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_
Agricultural 01dunicipal/Public %
Geothermal(Heating/Cooling.Supply) OResidential Water Supply(single) fL R,
hrdustrial/Commercial [31tesidential Water Supply(shared)
`IS:GROUT ,.• .... ..
'V.hri ation FROM TO .. RfATERLIL �EMPLACEMENT METHOD-.&AMOUNT
Non-Water supply well: 0 ft. ft deri'►evY
Monitoring ORecovery ft ft.
Injection Well:
Aquifer Recharge E]Groundwater Remediation It ft.
4%SAND/GRAVEL;PAC&ffa licatile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwaterIhainage R• ft.
Experimental Technology OSubsidence Control fL %
Geothermal(Closed hoop) OTracer `20zDRIL•LiNG'LOG`attach additionigI sheets if necessa
Geothermal(Heating/Cooling Return) 00ther(explain under 421 Remarks) FROM ft TO DESCRIPTION(color,hardness,sai0rock rainsiz etc)
4.Date Wel[(s)Completed: 2 .,?2Well ID# ' ft 116 53A iVJ Z C IL! ' mud
5a.Well Location: (j IL fL 13Ju ' L-Z0 ru t'
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft ft L
7c; tom)- G' Clnc��e LIti, C51ZC'1FilJc}17QiZQ l tCi ft. ft
Physical Address,City,and Zip + {_ ft. ft
M.;i I Pig lza
Comity Parcel Identification No.(PIN) D«
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5b.Latitude and.longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
lv yr
6.Is(are)the well RR ermanent or ©�Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certhy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 K dl Construction Standards and that a
Iflhis is a repair,fr/l out known weB,construction information and explain the nature of the copy ofthis record has beenprovided to the well owner.
repair under 421 remarks section or on the back ofthiv form. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page Ito 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:�V J (fL) 24a. For All Wells: Submit this�form within 30 days of completion of well
For mulaple wells list all depeks jdifjerent(example-3Q200'and 2Q1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing.Unit,
If ivater level is above casing;use"%+' 1617 Mail Service C ranter,Raleigh,NC 27699-1617
11.Borehole diameter: V? 0-) 24b.For Iniection Wells: In additiol to sending the form to the address in 24a
12.Well construction method: 1 � J ad I above,also submit one copy of this form within 30 days of completion of well
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(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
13a.Yield(gpm) V Method of test_ + 24c.For Water Supply&Iniectionl Wells: In addition to sending the form to
r r� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 7 Amount:-"f 0-z— 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 Resources 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 27401�
Record of Construction, Repair, or Abandonmcent of a Well
Address of Well:Zj-5-' k ilA l i' A L i k Lo l)z rt:lv.`abO R O LATITUDE 3
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Well Permit Number. 21) ' 1 -&JIV 141z - to 7 d 3 LONGITUD4
Well Contractor Company: k-!1C-- ��+ -�- - Completion Date: ;7-2
Total Well Depth:2 0�_ft. Well Yield: d. gpm Static Waterr Level: 30 ft.
Grater Casing Material:5 biz , l i�:U `C Formation Log
Casing Diameter:2 in. Casing Depth: . ¢�ft. Depth Descri tion
From:.oft.To: ft.
Inner Casing Material: From:�_ft.To:I Eft.. Sal koC EI,
Casing Diameter: in. Casing Depth: ft. From:A-�6 ft To: "�t. t�Jii �riz19 n1�`1 e
From: ft. To: ft.
• Grout From: ft. To: ft.
Depth Material Method From: ft.To: ft.
From:-C_ft.To:' b_ft. ce4,EA14 V 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: )76'ft. ft. ft. ft. fL " ft. ft.
Yield: T7 gpm gpm gpm gpm gpm I gpm gpm
Method of Repair:
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Method of Abandonment:
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I hereby ce that this well was construe rtify fed,repaired,or abandoned according to the Guilford bounty Well
Rules in effect on•this date and that a copy of this record has been provided to the well owner.
Well Contractor: Certification*: 0 Cs 60-f" Date:
Record of Pump Installation
Pump Installation Company:_ � 5-� i l / ��_ Completion Date: "-7 �--q Ja
Pump Depth: r 00 ft. Static Water Level: --" D ' ft.
Pump Brand: Pam- a -'-Sa--1 a.P j I,tS"P-(-Amp Size and Rating�: � i/J hp I� gpm
I hereby.certify that this pump was installed and wellhead completed according to they Guilford County Well
Rules in effect on 'l. ate that a copy of ' re rd has been provided to the iell owner.
Well Contrac Certif cation#:�R t r`� Date: �-"
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Revised:January 1,2009