GW1-2022-07149_Well Construction - GW1_20220804

flint Farm
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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David Hardy 14.WATER ZONES I
Well Contractor Name FROM TO DE N '
ft. pGft.
2906-A qf, -
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NC Well Contractor Certification Number I5.OUTER G'ASING(form r u�sEd wells'OR LI&ER if a 'ca e
Aqua Drill., Inc. reoM TO _ DIAMETER+ THICKNESS I MATERIAL.
CompanyName leINNER CASING OR TUBING otherma closed-loo)
J !r ESS
2.Well Construction Permit#: FROM��7 ��- ft. TO ft DIAMETER in.. THICKN MATERIAL
List all applicable well construction permits(i.e.UIC,Counol,State.Variance,eta) i
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DTAMCrER ;SLOTSIZE THICKNESS MATERIAL
Agricultural OMunicipaVP 'c ft. It. in
Geothermal(Heating/Cooling Supply) srdential Water Supply(single) ft. ft. in.
lndustrial/Commercial OResidentiai Water Supply(shared) fig,GROUT
Irci ation FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
:. Monitoring ORecovery ft. ft.
Injection Well:
ft. it
Aquifer Recharge [30roundwater Remediation
19.SAND/GRAVEL PACK if a licable
quifer Storage and Recovery OSalinityBarrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStornrwater Drainage
it. tt
Experimental Technology OSubsidenceControl ft. ft.
Geothermal(Closed Loop) I[ Tracer 20.DRILLING LOG fattach additional sheets Knecessary
' Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) FRoni To DESCRIRTIUN Color hardness soiUrock c rain 5iu,etc.)
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4.Date We4(s)Completed: - Well.ID# 1e. ic-�tt• i^ r�6 G e
-ft it �ryi .
Sa.Well Location: � 41� .0 (.a
Facility/OwnerName. Facility ID#(if applicable) [t. ft.
/ ft. ft
P;7'
al Address,City,and N //'' ft ft I A I ' R 2022
s, �tY+ Pf,1 ' i
t o/ 6 l;5 21.REMARKS i R
county Parcel IdentificationNo.(PII� lftE0f9ft3Oi1 PrL`t;.xiid:tk�URGi
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell ld,one 1pat/long is sufficient) f _ 22 •e 'ficatiot)�
Si maturee of Certified Wall Con r Date
6.Is(are)the well(s)[3Permanent �•or Temporary b
By signing this farm,I he certtf}that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or No"—' with 15A NCAC 02C.010 o,-15A NCAC 02C.0200 Well Construction Standards and that a
1f this is a repair,fill out!Drown well construcdon information and explain die nature of the copy ofthis record has been provided to the well owner.
repair under•#21 renmrks section or on the back of this form. i
23.Site diagram or additional well detallsi
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: /f/ (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdii ferem.(example-3@200'and 2�ai 100) construction to the following:
10.Static water level below top of casing- (ft.) Division of Water Resources,Information Processing Unit,
Iftvater Level Is above casing,use"+" 1617 Mail Service Ci nier,Raleigh,NC 27699-1617
11.Borehole diameter: � (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
� �Q�/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:GYP J 6 construction to the following'.
(i.e.auger,rotary,cable,direct push,etc.) -
Division of Water Resources,Underground Injection Control Program,
FOR WATERSUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
..yL i•
13a.Yield Wm) Method of test; c / 24c.For Water SUDDIv&Injection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: `/ Amount: 0 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

i
I
GUILFORD COUNTY D��PIaTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W.Market St.,Suite 300,Greensboro,NC 2740111
Consthructla%,7rapo an., (01F Aband(OHMIlent oha WOU
Address of Well:jy�L& �' ljrA �r (fir F�S�Jd /(/�� --LATITUDE �' j3f�
"Veli Permit Number: �� l(�1 C{-�?4`" `OHGITUDEi ,
Well Contractor Company: ct 4 11, it Completion Date:
Total Well Depth: Well Yield:/_,pm Static Water Level: ft.
Outer Ca51mg teiial: -Formadon Legg
Casing Diameter: 41a, Casing Depth- ,C� si. Depth ti D scrxp�an
From: To��ft. : ./
Inner�Casumg Material: From: _st.To:�ft. .,
Casing Diameter: in. Casing Depth: ft. From;s-ft. TO. Zl-ft. G f� /�
Fraxn:'�G?it.T0:�ft. .l�,
Grout From: ft.To:
From:
Depth Material Method From: ft. To: ft.
ft.To: it.
From: ft.€o: ft.
From: fl. T o: ft. Frol�.: it.To: �.
From: ft. To: ft. From: -ft.To: i
l� 1,7 U,er P l'odu"d°don Zones
Depth: ���t. 1 ft. >�I ( S_1t. &
Yield: gpm b' n gPm -pm gpm
gpin gpm
i
Method of Repair: .
Method of Abandonment:
I hereby certify that tlus well was constructed,repaired,or abandoned according to{the Guilford County Well
Rules in effect on this date d that a copy of'chi record has been provided to the well owner.
� r
Well Contractor: Mate Number: Date:
Record of pairamp Ensta Madan
Pump Installation Company: ; �� _ Completion Date:
Pump Depth: Q ft. StaticWater Level: fl.
Pump Brand: SAy t-�\C� 1 Q —i1 D�i'utnp Size and Rating: 3 hp C( S°pin
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on this ate a d that a co y o tlii record has been provided to the�vwll owner.
State
Well Contractor:
�_ �sulnber:_ �__ Date: