GW1-2022-07153_Well Construction - GW1_20220804

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATERZONEs. . :. .
Well Contractor Name FROM TO IDESCRIPTION
2080-A ?,,,(met,
ft. ft.
NC Well Contractor CertificationNumber
15..OUTER CASING(foc multilcasW*ft)' LINER(of applicable).,,-,
Aqua Drill, Inc. FROM I TO DIAMETER THICKNESS MATERIAL
O ft- S/1 ft. l � in C
• Company Name C� � J
f/r / 7 Q 16s1NNER'CASING.OR.TUBIN eotlierriral'closedloo s.:?'. _
2.Well Construction permit#: 1,2 ! lJ AJ#R "166 / � FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC Cmmty,Stag Variance,etc.) ft fL in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: =17 SCREEN
FROM TO DIAMETER •SLOT SIZE THICKNESS MATERIAL
._Agricultural []Municipal/Public ft ft, in.
Geothermal(Heating/Cooling Supply) •Residential Water Supply(single)
ft fL in.
Industrial/Commercial Residential Water Supply(shared) =1t1 GROUT _
� .i.
hn ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water SupplyWell:
-Monitoring _'Recovery ft. ft
Injection Well: '
ft %
Aquifer Recharge Remediation
.19:SAND/GRAVEL PACK rf a'-Itce6le .
Aquifer Storage and Recovery OSalinity Barrier FROM To IMATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft
Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) DTracer -20.'DR1LLING`LQG attachudditionalshecfsifnecessa
Geothermal eating(Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soltlrocktype, n size,etc
�7 q ft. ft
[
4.Date Well(s)Completed: / —1 L- 2.�W U ID# ft' v ft 5 j tust 9 r
5a.Well Location: IL '5 0 s"ft' [J Ici G m4i r
ft. &
Facility/Owner Name Facility lD#(if applicable)
fL ft I V OF
Physical Address,City,and Zip ( ft ft.
6 tZG, � C �21:REMARKS l_
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D%VQISOG
(if well field,one lat/long is sufficient) 22.Certification: /�/
N W Y ` •
6.Is(are)the vvell(s)&Permaneut or OTemporary Signature of CErtified ell Conttactor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or ta10 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has.been provided to the well owner_
repair under#21 remarks section or on the back of this farm 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 I
9.Total well depth below land surface: J L5 00 24a.For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a 00'and 2@100) construction to the following: i
10.Static water level below top of casing: -30 00 Division of Water Resources,Information Processing Unit,
If water level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Tniection Wells: In addition to sending the form to the address in 24a
12 Well construction method: 1 2 t'��l[l 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.)
I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
CC�
13a.Yield(gpm) Cl Method of test: ,GuT 24c For Water Supply&Tniection Wells: In addition to sending the form to
/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:,/) Amount 0 L completion of well construction to I'(.county health department of the county
where constructed. I I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i. Revised 2-22-2016

G I
UIL.FORD COUNTY DBPARTIVIENT OF PUBLIC HEAL.TH
Division of Environmental Health,Water Quality Unit
400 W.Market St.,Suite 300, Greensboro,NC 274011' j
Record of Construction, Repair, or Abandonment of a Well
Address of RTell: 7,5-0( L~�1 &J / e,Nsh-n CLARTUDE 3
rt �2© av
Well Permit Number: Q -12 -&JAJ R - 106 LONGITUDi
Well Contractor Company: � �� + ,- - - Completion Date: 7-1 a-2-9—
.,
Total Well Depth:3 _ft. Well Yield; _gpm Static Watei Level:_ ft.
Outer Casing M atenal: Z Formation Log
Casing Diameter: in. Casing Depth: jd,S ft. Depth Description
From: 6 ft.TO:�ft,
Inner Casing Material: From:-Z—ft.To.='G ft.
Casing Diameter: in. Casing Depth: ft. From:-S-0—ft.To;20-3-,ft. ,I-Jc;r-
From: ft. To: ft.
Grout From; ft. To: ft. '
Depth Material thod From: ft.To: 'ft.
From:--a-ft-TO:16 ft. 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• �ft. ft. ft. ft.
Yield: 5" gpm 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 they Guilford County WolI
Rules in effect on•this dat and that a copy of this record has been provided to the well owner.
Well Contractor. Certification#; ao6 '` Date: -a2aZ
/Record of Pump Installation
Pam Installation company. > c� i r`p .�. �, i Completion Date: -7 �
Pump Depth: (2-757 ft. Static Water Level: 3 C� ; ft.
i
Pump Brand: O�� i aM i[7c�-r�l USIA 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 to that a copv oflfis record has been provided to the we]l owner.
Well Contractor. �:—� Certification#:`�� f Date.
Revised:January 1,2009
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