GW1-2022-07706_Well Construction - GW1_20220811

Fr nt.Form
WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
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1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
2080-A gg
NC Well Contractor Certification Number O ft ft S,0
15.OUTERCASING formWticasedwells OR LINER ifs 6cable
Aqua Drill, Inc. FROM TO ``DIAME®TER THICRIVESS i MATERIAL
Company Name © ft. -2 ft. GO B$ m 5 p z 2( I P;V
/'�/ _ (�J 36:INNER-CASING OR TUBING' eothermal blosed400
2.Well Construction Permit#:,22-vV" �YU I��(�'�1 1��)� FROM TO DIAMETER THTVWNEss ,MATERIAL
List all applicable well construction permits(i.e.UIC,Cmurty,State,Variance,eta) ft• it. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.8CREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
HAgricultural []Municipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft ft in
Industrial/Commercial DResidentiaI Water Supply(shared) 18:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: It 0 ft. %
Monitoring I Recovery ft. th
Injection Well:
3A uifer Recharge ft. ft
- Aquifer erge �GroundwaterRemediation
Aquifer Storage and Recov ��"7 MSAND/GRAVEL"PACK di liable
q g L�fS� tY Sallie! FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft
Experimental Technology 0Subsidence Control ft ft
_Geothermal(Closed Loop) DTraccr 20:DRQ LING LOG attach additional sheets if necessary
Geothermal eatin Coolie Retum _'Other FROM TO DESCRIP ION color,hardness,wiltrock size etc.)
1; (explain under#21 Remarks
�y �/ ft. ft f C. y� c
4.Date Well(s)Completed: c wr u ID# L o 1- �-•7 tt ft L� 4T` '
Sa.Well Location: ft ft L3 ,,G :g m 1
fL ft.
Facility/Owner Name Facility ID#(if applicable) ft• ft R "
6q7't l� r-�► iU e-i&JK R ft
Physical Address,City,and Zip H. I
,21:REMARKS - '
12022
County r, Parcel Identification No.(PIN) *'+, procopairm[hum
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W JL�J V-4—
6.Is(are)the well(s)OPermartent or OTemporary Signature ofCcrtified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes oroo 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 ropy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
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
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulaple wells&I all depths ifd ffereru(example-3�00'and 2@1001 construction to the following:
10.Static water level below top of casing: 30 d (ft) Division of Water Resources,Information Processing Unit,
Ifnuter level is above casing,use"+" 1.617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 111
/� (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method !-t I] �)�i � ' above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following.
Division of Water Resources Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
��ry•y
t
13a.Yield(gpm) Jtf 0 Method of test: 24c.For Water Supply&Iniection 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 6 completion of we]I construction Ito 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
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GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health, Water Quality Unit
400 W. Market St.,Saute 300, Greensboro,NC 27401
Record of Construction, Repair® or Abandonment of a Well
Address pf Well:(,/,�/75� /Zara� x 1 Z d %l e,6,0w�-
t CLATITUDE 3
Well Permit Number: L-61 yv j - Q q 9 c l —
�� LONGITUDE
Well Con�aetor Company:
Completion Date:
Total Well Depth: 0 S- ft. Well Yield: JG 0 gpm Static Water Level:
Outer Casing Material: Q jZ 2— � , �/r C
Casing Di4.meter: �, ASS in. Casing Depth: 70 ft. D Formation Log
Description
Inner Casan From: -ft To:� ft.
g Material: X P 1�l _ _
Casing DiAin : in. Casing Depth: ft Fi°m'�2, ft. To. _ft. 5 _ v
p From:jkiEft.To:10, - fz c
Grout
From: ft. To: ft.
From: ft. To: ft,
bepth Material thod
From: ft.To. ft. From: ft. To: ft.
From: To:.�_ c�"ri► zwz - From: ft. To: ft.
ft
From: `ft. To: ft,. From: ft. To: ft.
From: ft. To: ft.
Water Production Zones
Depth: �ft. 90 ft
Yield: L gpmC?gp�n ft' ft.
gpm gPm gpm gpm gpm
Method of Repair:
Method of Abandonment:
I hereby certify that this well was constructed,repaired,or abandoned according to the 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: `
State Number: M Date: -1 ' ZZ
E
Record Of Pump Installation'
Pump Installation Company:_ �, �,,ti
r Completion Date: rr -;P�
Pump Depth: ft. Static Water Level: oZL(,:)
Pump Brand �'� o�� c�,--?aP�•-". 1
--� u Siee and Rating: hp gpm
1 hereby certify that this pump was installed and wellhead completed according to the 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, `
State Number: �' Date: /