GW1-2022-07154_Well Construction - GW1_20220804

WELL CONSTRUCTION RECORD(GW 1) -
Pnrit Farrn :,
For Internal Use Only:
1.Well Contractor Information:
Chris King
14:WATERZO
Well Contractor Name FROM TO DESCRll'TION
2080-A ft Z f
NC Well b-tractorCertificationNumber It ft.
Aqua Drill, Inc. 'i5--OUTER CASING.foriMlti-casedivelis OR LINER tfa licatiler .
FROM TO DIAMETER TffiC L; (is MAIERIAL.
Company Name 6 ft 3 ft �'; 'in.
� 5� �
I6:INNER"CA INGARTUBING., eothermauclosedloo
2.Well Construction Permit#: '�)J FROM TO DIAMETER:` TIffCKNESS MATERIAL
List all applicable well:construction permits(i.e.UJC,Counh;Stag YariancG etc.) ft• ft 1 in
3.Well Use(check well use): ft. ft In.
i
iGe:othur:mall(HeatiglC..ag
ter Spply WeD: 17:SCREEN -777
- s
cua FROM TO DIAMETER I SLOTSIZF� TRiCKNFSS MATERIAL
QMunicipal/Public ft. it in
Supply) residential Water Supply(single)
ft. in.I
InduSftbVCommercial oResidential Water Supply(shared) ft.
Irrigation =:. .:.. ., �..,
FROM TO MATERIAL EMPLACEl1•IENT METHOD&AMODN'r Non-Water Supply Weii: ft. 0 ft.
Monitoring [.Recovery ft. vc
zz
Injection Well: ft
Aquifer Recharge oGroundwater Remediation ft. ft.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK tf a""Iicabie r.
FROai TO MAT
ERIAL EMPLACEMENT METMOD
quiferTest ,oStormwaterDrainage ft ft.
Experimental Technology oSubsidence Control ft. ft.
Geothermal(Closed Loop) W��•�l,Tiacer
5.20:DRILLIN�11Gch addrtioiial'sheets if riecessa )
RGeothernial(HeatinglCooling Relum) Other(explain under#21 Remarks) FROM DESCRIPTION colb,hardness sofvrack It.
4.Date Well(s)Completed:2'/F-e - Well ID# ft. M
S. Yo
. c� tz
5a.Well Location: s- It .2
L � I
it It
Facility/OwuerName Facility IM(ifapplicable) ft. ft. ,
r11 ft. ft. t�
Physical Address,City,and Zip ft ft i
�7 3 21 REniARKS: � _
County Parcel Identification No.ly" I +
Infon
URN
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ! DWQ/8OG
(Swell field,one lat/long is sufficient) 22.Certification:
x W
6.is(are)the wells) Permanent or Temporary signature Certified Well CDnoacror Dace
By signing this form,I hereby certify that they wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes oromo with 15A NCAC 02C-0100 or ISA NCAC 02C,.0200 Well Construction Standards and that a
Ijthis is a repair,fill out known well construction information and explain the nature of ehe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form.
23.Site diagram.or additional well detiits:
8.For Geaprobe/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 ifnecessaty.
drilled:
P SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S (fL)
For multiple wells list all depths ifd fferent(example Q200'and 2QI00) 24a•For All Wells: Submit this form I within 30 days of completion of well
construction to the following:
10.Static wafer level below tap of casing:Jjivater level is above easing,use (ft) Division of Water Resources,Information Processing Unit,
'4"
r 11.Borehole diameter: 1617 Mail Service Center Raleigh,NC 276994617
{o (in•) f
24b.For Injection Wells: In addition to Isending the form to the address in 24a
12.Well construction method: R ) ; above,also submit one copy of this fomtl within 30 days of completion of well
(ie.auger,rotary,cable,direct posh,etc.) construction to the following-
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994616
13a.Yield(gpm) Method of test: . r - 24c For Water Su 1 &In'ection Wells:-In addition to sending the form to
136.Disinfection type:
the addresses) above, also submit one copy of this form within 30 days of
_ Amount Zd t�Z completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources
Revised 2-22-20]6

i
GUILFOiID COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit 1
400 W.Market St.,Suite 300,- Greensboro,NC 27401
Record of Construction, Repair, or Abandonment of a Well
Address of Well'Q. ' =0 t.anrune S
Well Permit Number: 5--(,J (Z - 3 313 LONGITUDE
Well Contractor Company: r-�\9Lk.,,�Gt Completion Date:? '/
Total Well Depth: S ft. Well Yield: gpm Static Water Level: ft.
Outer Casing Material Formation Log
Casing Diameter: in. Casing Depth: Cj ft. Depth Descri tion
From:n ft.To:6 j ft. Vr.8 C
Inner Casing. Material; From: jo ft.To:2S__1_ft.. 5xlru T�6cL-
Casing Diameter: in. Casing Depth: ft. From:.2, ft.
From: ft. To: ft.
Grout From: ft.To: ' ft.
Depth Material Method From: ft. To: ft.
From: ft.To•ZG ft. dt)21� l ec c1 From: __ft.To: ft.
From: ft.To: ft. From: ft. To: ! ft.
From: ft.To: ft. From: ft.To: ft.
Water Production Zones
Depth: O(7 ft. ft. ft. ft. ft. ft. ft.
Yield: %2 gpm gpm gpm gpm g'Pm gpm gpm
Method of Repair-
Method of Abandonment:
i
I hereby certify that this well was constructed,repaired,or abandoned according to the Guilford County We]I
Rules in effect on•this date and that a copy of this record has been provided to the well owner.
Well Contractor:� iL_ � Certification#: �Q�p� Date:
Record of Pump Installation
Pump Installation Company: L �' I Completion Date: -_7 is-fo-
Pump Depth: (CO( ft. Static Water Level: ft.Pump Brand:��`wrx SS t' 1 Sr y Pump Size and Rating:f 145
hp_ gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on e d that a co of this reco d has been provided to the will owner.
tl- --
Well Contractor: Certification#: � Date:
i .
1
Revised:January 1,2009