GW1-2022-07155_Well Construction - GW1_20220804

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`P'n't Form•'a
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATERZONES:.
WellContractorName FROM - TO DESCRIPTION
2080-A 4 ft ft. 30( )
It ft
NC Well Contractor Certification Number ;15.OUTER CASING Mi mNti cased"well's,OR LINER.d.a' ticaGle
Aqua Drill, Inc. FROM TO DIAMETERS
M4ARIAL
CompanyName 0 ft. 0 Z i V 1 c
`� /' '16--DMR:CASING20R-TUBING eiitHei•mnlctosed-lao' l�
2.Well Construction Permit#1C2 r(,f,�C �(� U J�JJ J FROM I TO DrAMETER zH1CKNESS ^MATERIAL
List all applicable well construction permits ri.e.UIC,County,Stag Variance,eta) ft ft + in
3.Well Use(check well use): ft. ft I; in.
Water Supply Well: �17.SCREEN-,,,
FROM TO DIAMETER SLOTsrLE THICKNESS MATERIAL
i_+Agricultural DMunicipal/Public ft. ft. in .
Geothermal(ITeating/Cooling Supply) Residential Water Supply(single) it, p• in
Industrial/CommercialResidential Water Supply(shared) 18.:GR0DT =: `
:._
.. Irrigation FROM TO MATERIAL -EMN ACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. 0 ft.
:-'Monitoring DRecovery ft. ft.
Injection Well:
ft._.Aquifer Recharge OGaoundwater Remediation it
`.I9;SAND/GRAVEL.PACIG if a `licable
Aquifer Storage and Recovery Salim Barrier -
tY FROM 'TO M1fATERrAL ' EMPLACEMT:NT METHOD
!Aquifer Test oStormwater Drainage ft ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer v DRILLUVG';LOG attach additid at sheillif iiecessa '
Geothermal eating/Cooling Return) MOther(explain under 921 Remarks) FROM TO DESCRIPTIOR(color,bardness,witimck a rain Sim eta))
IT
ft. ft. �'
1'
4.Date Well(s)Completed: .-I-5 :,ZYZ Well ID#/CO-� (0 1 c� ft ( (j ft _
3a.Well Location: V ft. ft. C•
ft. &
Facility/Owner Name Facility ID#(if applicable) ft ft
�L/S9�: Ir �J1 Cl�� J Y1 TI t�PLC�X1n t ft. ft ...r
Physical Address,City,and 71p ft. ft
At
/Sri t_1 t �o2 21.REMARILS: .
sty Parcel Identification No.(PIN) n, a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DVI 3013
(if well field,one lat/long is sufficient)
22.Certific lion: ! '
x W T t
6.Is(are)the wells)t Nrimment or OTemporary Signature ofCenifie ell Co toi• Date `
By signing this form,I hereby certlj},that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or E]NO with ISA NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ijtlris is a repair,fill out knoavr well construction information and erpWn the nature of the copy of this record has been provided to the we11 owner.
repair under#21 remarks section or on the back of thisform.
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 ifnecessary.
drilled:
�f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '0'-�-J (10 24a.For.All Wells: Submit this form',within 30 days of completion of well
For multiple wells list all deprhsffdifferent(example-3(200'and 2@1003 construction to the following:
10.Static water level below top of casing: 3 (ft.) Division of Water Resources,Information Processing Unit,
Ijwater level is above casing,rise"+" 1617 Matz Service Center,111aleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: J2tZ I above,also submit one copy of this form within 30 days of completion of well
(ie.auger,rotary,cable,directpush,etc.)
construction to the following.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matt Service Center,Raleigh,NC 27699-1636
13a.Yield m
(gP ) 0 Method of test: �J��►�� 24c.For Water Supply&Injection Wells: In addition to sending the form to
o the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:-? O-z- completion of well construction to the county health department of the county
where constructed. lI
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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:��f `� '�' l�C n t 5k6&0_ &,�LATJ ITUDE 3—
Well Permit Number: ��N j-}jZ ® E i LQAi�tTUDE
Well Contractor Company: 'k_tc_ 1 _=1_r Com ' - o�pletion Date -2
Total Well Depth: A.2��ft. Well Yield: m
gp Static Water Level: ft.
Outer Casing Material:SD p 2 l P, f IForntation Log
Casing Diameter:d!2 -An. CasingDepth; .z Depth De cri lion
l? L � � p
From. ft. To.l ft.
Inner Casing Material: From: ft.Taft.
Casing Diameter: in. Casing Depth: ft. From 0 ft To ft.
From: ft.To: ft.
Grout From ft.To.• ft.
Depth Material Method Front: ft.To: ft.
From0_ft,To;,1Wft. e uC 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. ft, ft. ft.
'Field: 3 gpm 9Pm gpm gpm gpm gpm gpm
Method of Repair:
Method of Abandonment: ;.
I hereby certify that this well was constructed,repaired,or abandoned according to tFe Guilford County Wolf
Rules in effect oirthis date and that a copy of this record has been provided to the well owner,
Well Contractor: Certification#: 20 - Date: a.2Z i
Record of Pump Installation
Pump Installation Company. :D,4 I, , �1 C Completion Date:
V
Pump Depth: l Q(7) ft. Static Water Level:_
Pump Brand: ��-tP- d� 'S�- lit Lam mp Size and Rating. ` � hp 1 gpm
I hereby certify that this pump was installed and wellhead completed according to thebuilford County Well
Rules in effect on thi date ayfi that a copy of is record has been provided to the well owner.
1
Well Contractor: Certification#: 1a9 C)('�^PrDate:
i -
Revlsed:January 1,2009
I