GW1-2022-07156_Well Construction - GW1_20220804

it
Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
L Well Contractor Information:
Cameron BaziR 14.WATER ZONES I
Well Contractor Name FROM TO I DESCRIPTION
4518-A US m ft
NC Well Contractor Certification Number fr. ft I I �
15.OUTER CASING for mul4-cased wells ORLIlNERff a licable
Aqua Drill, Inc. r•ROM xo D1011T,R THICKNESS MATERrAL
ft ft j in.
CompanyName 2 1.
` 16.INNER CASING ORTUBING eothermalclosed-loo
2.Well Construction Permit#: i�l D� FROM TO IMANEM11 I THICKNESS I MATERIAL
List all applicable well construction perndts(i.e.UIC Coun0l.Stal4 Variance,etc) fL ft I I I.
3.Well Use(checkwell use): tt, ft ! in.
Water Supply Well. 17.SCREEN
FROM TO DTAMEIER I>SLOT SIZE THICKNESS. MATERIAL
Agricultural DMunicipM`.blic % it. in.
.. Geothermal(Heating/Cooling Supply) JffRwidential Water Supply(single) ff ft, in.
IndustriaUCOmmereial 011esidential Water Supply(shared)
IS..GROUT
i IrriRation FROM TO MATERIAL EMPLACEMENT METHOD.&AMOUNT
ElCooling
er Supply Well: o ft D_ c ft
ring nRwvmy R J'lj
Well:Recha a ft
ElGroundwaterRemediation
Storage and Recovery Salmi Bonier 19.SAND/GRAVELPACK ifa licable tY FROM TO htATmrAL' EMPLMENTMETHOD
Test OStormwaterDrainage ft. %
ental Technology Subsidence Control ft. %
mal(Closed Loop) DTM= 20.DRILLINGLOG attach additional sheets if access
ral(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DES color hardnes,soNcock a size,ete.)
4.Date Well(s)Completed: &Y—Well I # S n Q sroc II
Sa.Well Location: ft%
('� "e-S it
E►o
Fa Name Facility lD#(if applicable) fL
?41 g- t—f fI6 (�llwf'G �.t•� Ica fL 5.
,.
Physical Address,City,and Tap ft, ft
C'SG.t[ff�J( �itlr'n�tf-1/ 21.REMARKS r ., �
County 7
Parcel Ideruifica6on No.(PIN) a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DtiAM18013
(if well field,one lattlong is sufficient) 22 Certification:
G. I S 37 rr `ICY$ w i
6.Is(are)the well(s) `-" ermaneut or iOTemporary Si ofCertifi Well Contractor Dater
e By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or ONO with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repa r fill out!Drown well construction informatio1(and explain the nature of the CIPy ofthis record has been provided to the well owner.
repair under#21 remarks section or on Jre backofthisforvi
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havingthe 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:
SUBAHTTAL INSTRUCTIONS I
9.Total well depth below land surface:_ O
Formuhi le wells f i ( p ( 24a.For All Wells: Submit this form within 30 days of completion of well
P depths i di different ezanr le-3 00'and 2 100 construction to the following t
I0.Static water level below top of casing: -5o
jwater level is above casing use + —(ft) Division of Water Resources,Information Processing Unit,
1617 Mad Service Center;Raleigh,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: of'% above,also submit one copy py of this fo i within 30 days of completion of well
(Le.auger,rotaty,cable,dircetpusb 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
m 75)
13a.Yield(gP Method of test: 24c.For Water Supply&Infection Wells: In addition to sending the form to
y- the address(cs) above, also submit one Copy of this form within 30 days of
136.Disinfection type: / Amount: Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Envimnmentai Quality-Division of WaterResources
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 ®f Construction, Repair® or Abandon went of a Well
Address of Well: _ 7GZ LJff(L GGat� Ls, e#"5ba1r10 LATITUDE 3 L 15837
well Permit Number: 2(- 12- "W/V K- joacl1 LO rali,UDE 79-- 9VC33
Well Contractor Company:p Y AaAA' dill Completion Date:
Total Well Depth:_ 185 ft. Well Field: rpm Static Water Level: O ft.
Outer Casing Material: pVG Form tation Log
Casing Diameter: j,' _in. Casing Depth: $Z ft. Depth Description
From: O ft.To:7 _ft. �a
Essnaea-Casing Material: From:_5­ft.To: 18S
Casing Diameter: in. Casing Depth: ft. From: ft.To: ft.
From: ft.To: ft.
Grout From: ft.To: ft.
Depth Material Method From: ft.To: ft.
From: 0 ft. To:?, ft. Germ-- -IZ,_ From: ft.To: ft.
From: ft. To: ft, From: ft.To: ft.
From: ft. To: ft. From: ft.To: ft.
Water Production Zones
Depth: L65 ft. ft. ft.
Yield: -7. 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 toithe Guilford County Well
Rules in effect on this date and that a copy of this record has been provided to the well owner. !
Well Contractor: Certification#: Date:
Record of Pump Installation
Purn Installation Company: ,i-�� �,r� �,
P . � � Comp `etion Date:
Pump Depth: [ Q ft. Static Water Level: L4�I ft.
Pump Brand: fy'\--(er-S a-5 ti I a€'r 5 M-rpp Size and Rating: hpf G) gpm
I hereby certify that this pump was installed and wellhead completed according to tlie,Guilford County Well
Rules in effect on thi• to d that a copy thi. record has been provided to the weell owner.
Well Contractor: Certification#:C Date: —
Revised:January 1,2009