GW1-2022-09152_Well Construction - GW1_20220930

WELL CONSTRIICTION RECORD GW-1 Print rorm
For Internal Use Only:
1.Well Contractor Information:
Chris King
Well Contractor Name 14.WATER ZONES
FROM TO DESCRIPTION
2oso-A �ft -71 6
NC Well Contractor Certification Number ft' ft.
I Aqua Drill, Inc. IS.OUTER CASING formWti-ca'sedwells OR LINER tfa livable
FROM TO DWMETER TFUCIKNESS MATERIAL
ComparryName 0 ft ({ ft i` �e? in. a 01L
2.Well Construction Permit#. `�) )r� h, _ 16.INNER CASING OR TUBING' eothermal closed-loo
t
nJ7�-�(�
List all applicable Weil construction p¢rnrtty(i.e.U!G Cos FROM TO DLOMTER TIUCKNESS MATERIAL i
mtli State,Frarlanc4 etc) ft. fL In.
3.Well Use(check welt use):
ft• ft, in.
Water Supply WeD:
17.SCREEN
-AgriCuttural FROaf TO DIAME TER SLOTSFZE TFR
MtDncrpaUPubltC ft. $ CKNFSS MATERIAL
Geothermal(Heating/Cooling Supply) X-,dential Water Su ) in.
hmdusrtriaU �l
Coervial PP Y(single) ft fL ;n
DResidential Water Supply(shared)
I ri on IS.-GROUT
Non-Water Supply WellOa1 To MATERIAL EntPLACEMENTME7goD&AMotnvr
Monitoring 0 IL CCi�N
Injection Well: overy fL ft
Aquifer Recharge DGmundwater Remediation ft' ft•
Aquifer Storage and Recovery DSalinity Barrier 19.SANDIGRAVEL PACK tf a livable
Aquifer Test 1^�11 FROni TO MATERIAL
r,_,YStormwater Drainage ft. EMPLACEMEt1T METHOD
�S
.. Experimental Technology ft
ubsidenceControl ft. ft
Geothermal(Closed Loop) ;0-TM.
Geothermal(Heating 2o.DRILLING LOG attach additional sheets if accessa
�/Cooling Recur) Other( lain under#21 Remarks) FROM To DESCRIPTION(color hazda s0ft/mck rein sin,etc
4.Date Weil(s)Compl fL ZCi
C eted?9 Well 1D# 3
ft. ft.
5%Well Location: Ski C rZ0`G l�
It. 8 C_- t t
ft
R
FaciiitylOwner Name
Facility IDk(if applicable) ft f6
ft .ems
ft. s....�
Physical Address,City,and lap
21.REMARI{S
County
Parcel Identification No.(PIN) Ifilt
.9 Un i
b.Latitude and longitude in degrees/minutesiseconds or decimal degrees:
(ifwelm ficld,one fatllongis sufficient)
22.Certifi 'on:
W .. .f
6_Es(are)the well 7V(s) ger,r,anen[ or I 1 > "",2 2 Temporary Signature of Certified Well Contractor Date
7.Is this a repair to an existing well: oyes or ld]No By signing this form,!hereby certh,that;the weli(s)was(were)constructed in accordance
!f this is a repair,frll old(mown Nell construction Information and erplaia the nature of the oluiswith 15A record has been provided to the well0m�ner ell Construction Standards and that a
repair under#21 remarks section or on the back oft/risform
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 23.Site diagram
or back of this additional well details:
construction,only 1 GW-1 is needed. YOU may P�to provide additional well sine details or well
drilled: Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary,
9.Total well depth below land surface: �d S� SiTBMFITAL INSTRUCTIONS
FormufinferveUs list a11depthsifdlffereat(ew/nple-3Q2 000'and2 @I003 (ft 243•For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: construction to the following.
lfrwtterlevel is above casing use + (ft') Division of Water Resources,Information Processing Unit,
11.Borehole diameter: (/� 1617 Mail Service Center,Raleigh,NC 27699-1617
f�)
t 24b.For In action Weiis: In addition to sending the form to the address in 24a
(Le.anger,rotary,cable,direct st �`� above,also submit one copy of this form within 30 days Of completion of well
.Well construction p� etc.) construction to the following_
=WATERPPLY WELLS ONLY; =te-W&
Division of Water Resources,Underground Injection Control Program,
-�- 1636 Mail Service Center,Raleigh,NC 276994636
Method24c.For Water SuDDIv&Injec Wells: In addition to sending the form to
ype•-�_ the addresses) above, also submit one copy of tits form within 30 days of
Acomplexion of well construction to Form GW-1 where constructed. the county health department of the county
North Carolina Department of En"conmental Quality-Division of Water Resources i
i
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: [2c�3� `� �rJ ICLATi7 UDE 3
Well Permit Number:9�_�1 - �S N 0 Z -Q 0�-�(� LONGITUDE Y
Well Contractor Company: Completion Date: -,2 J 2 2_
Total Well Depth:Ste_ft. Well Yield: gpm Static Water Level: ft,
Outer Casing ``,lylaterial: S,D IZ - Zf Formation log
Casing Diameter: C� in. Casing Depth: . ft.
DepthDescription
From: Q ft. TO:3 ft. p ex-1 �J
Inner Casing Material: From:_ft.To:)_a_ft..
Casing Diameter: in. Casing Depth: ft. From:j 9 ft. To:,�ft.
From: ft. To: ft. kh
Grout From: ft. To: ft.
Depth Material Method From: ft. To.--ft.
From: 6 ft.To:g,G _ft. e-�� From: ft. To ft.
From: ft.To: ft. From: ft. To: ft.
From: ft.To: ft. From: ft. To: ft.
Water Production Zones
Depth: 7a ft. ft. ft. ft ft fi
Yield: 2L`gpm gpm 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. Certification#,Z Date:C7 2 Z
Record of Pump Installation
Pump Installation Company:AAQ r`i
—Q-- 4` -L"y- Completion Date: 41
Pump Depth: I SO ft. Static Water Level: ft,
Pump Brand:Cr a��5� i amS'� �ipS0(7-- pump Size and Rating: hp_LD gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on th' ate that a copy of is record has been provided to the well owner.
Well Contractor. Certification#: oZ`ifll�` ` Date:
Revised:January 1.2009