GW1-2022-10697_Well Construction - GW1_20221205

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
L Well Contractor Information:
Chris King 14.WATERZONEs ._
Well Contractor Name FROM TO I'DESCRIPTION -
2080-A J(:z ft ICL ft t
ft. fr. + i
NC Well Contractor CettificationNumber :15.AUTERCASING focmulticasedwells OR LINER'd,a''llcahler'e.`
Aqua Drill, Inc. FROM TO DL4METER THICKNESS MATERUIL
it. ft. 16/ m• iZ Z A U �CompanyName
r1��pp '16>--INNER'CASD4G:ORTUBi1�G eothermal closed loo �. .
2'Well Construction Permit 9: 7 �l ll�I i� r(r, FROM TO DIAMETER : THICKNESS MATERIAL
List all applicable well construction permits(i.e,UDC,County,State, ariance eta) f ft• ft.
3.Well Use(check well use): ft ft in.
Water Supply Well: FROTH TO DTAML'PER SLOT SIZE THICKNESS MAT ERTAL
Agricultural DMunicipal/Public ft ft in.
Geothermal(Reating(Cooling Supply)IbMesidential Water Supply(single) fL fr_ is
Iudustrial/Commercial 011esidential Water Supply(shared) 18s GROUT ._. .•.n.., ..:,
bri tion FROM TO " MATERTAT, E M ACEMENr METHOD&AMOUNT
Non'-Water Supply Well: O ft 20 ft. tht� 7ELIC
C:_ Monitoring r-Recovery ft ft
Injection Well: L ft•
`._ Aquifer Recharge [)GroundwaterRemediation
19 SAND/GRAYEti:PACK,d a 'IIcSble ,.
' Aquifer Storage and Recovery DSalinity Barrier FROM To MATERIAL;. EMPLACEMENT METHOD
Test OStormwater Drainage ft ft•
Experimental Technology OSubsidence Control n ft
Geothermal(Closed Loop) 'Tracer JIFROM
L1NG,LOG,. Geothermal(Heating(Cooling Retum) Other(explain under#21 Remarks) TO DESCRIPTION color hardness,s Wroclt_ ft�77C4.Date We11(s)Completed: Nell ID# ft_ C ft 5a.Well Location: ft• ft �1 G 0lu-% e-
ftft. l
Facility/Owner Name Facility ID#(if applicable) ft ft.
55/dt, JCf'�� , -�cltiA r}' � Z�e71 2(� jet. ft ft
Physical Address,City,and Zip ft % i t- t^, L
e2LREMARKS.
County Parcel Identification No.(PIN) i ITl irT,c.rta
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certifica•on:
W
N Z2-
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6.Is(are)tbe.well(s) Permanent or Temporary SigoatureofCertifiedWellConnactar Date
By signing this form,I.herebv certify that 4he well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or 9No With 15A NCAC 02C_0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is,a repair•fill out known well cotatruction information and explain the nature of the copy ofthis record has been provided to the well,owner.
repair under.#21 remark 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 tti provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTALNUMBER,ofwells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS ,'
9.Total well depth below land surface: ft
( ) For All Weis: Submit this fomt within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(a3200'and 2Qa 1005 construction
1n1LM10n to the following:10. �
f Static water level below top of casing: 1
If water level is above casing,use"+"
Division of Water Resources;Information Processing Unit,
1617 Mail Service Ceoter`,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 1
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
above,also submit one copy of this form within 30 days of completion of well
/�t ii2 1 1 construction to the following: t
(i.e.auger,rotary.cable,direct push,etc.j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matt Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �C Method of test: t h 24c.For Water Supply&Iniection Wells: In addition to sending the form to
T r� the address(es) above, also submit brie copy of this form within 30 days of
13b.Disinfection type: I- l Amount: L completion of well construction to the'county health department of the county
where constructed 1
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I 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.,Suite 300, Greensboro,NC 2740
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Record of Construction,. Repair, or Abandonme. nt of a Well
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Address of Well: C1040 o5Cpjj e C ♦ &g. .k_ LATITOD'E 3
Well Permit Number:.4 1-:01 61 ii fa 9- C'�g l � � LONGITUDE;
Well Contractor Company:)Q0jq i t Completion Date:. o 3
Total Well Depth: ft. Well Yield:_ gpm Static Water Level: ft.
Outer Casing Material: 0 1 F, ✓°6 Formation Log
Casing Diameter:��,� in. Casing Depth: 9 9 ft. Depth Description
From: 0 ft.To: 6 ' Lft. K-64, C I ia-'/
Inner'Casing Material: From:QLft.To:t-ip' ft.. 5 m -j 8 -O C je
Casing Diameter: in. Casing Depth: ft. From:_q6_ft.To: ft. 31,j 6-AwA i�c
From: ft.To: ft.
Grout From: ft.To: ft.
Depth Material Method From: ft.To: ft.
From:0 ft.To:.2,0 ft. (2-- vit) iZ C From: ft.To: ft.
From: ft.To: ft. From: ft.To: ft.
From: ft.To: ft. From: ft.To: ft.
Water Production Zones
Depth: )6 0 ft. ft. ft. ft. ft ft. ft.
Yield: gpm gpm gpm gpm gpm gpm gpm
Method of Repair:
Method of Abandonment:
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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. r Certification#:e�0A 9(5 -A Date: 30 `,2 '�-
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Record of Pump_Installation ( r
Pump Installation Company: i'`G` �~ I — ` Completion Date:
Pump Depth: 3 C)D ft. Static Water Level: te 6. ft.
Pump Brand: 1ck-�`a-e , a m� r�. .�(I'If Pump Size and Rating�_hp gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Weil
Rules in effect on this date and that a copy of this record has been provided to the swell owner.
Well Contractor / � ' �' Certification#: I4i Date: 1
Revised:January 1,2009 1