GW1-2022-10820_Well Construction - GW1_20221209

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use only
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L Well Contractor Information:
Cameron Bazin Ia:wAZERzoNss'.. :: :;:r ":' ••.: ,. :. ...:,,...:
FROM TO DESCRIPTION I
Well ContraotorNarrc & ft i
4518-A %
NC Well ContractorCertifiwtionNumber is;OUTER. rormniti-cased- ORLUMrifa tic+tile°_ .•
Aqua Drill,Inc. FROM To Dr, mR Tm MAT>rtrtL
p ft 4].O ft to L,. �-
CompanyNarne v A 16.INNER'CASING'ORTIIBING' eothermnitWed-!d'o
2 . O • �r l _9'a FROM TO DIAMETER TMCHMS MATERIAL
2.Well Construction Permit#: ft ft to.
List all applicable ita constructionpermits fr•e VIC,County.Stare,Variance eta,)
g, 1n.
3.Well Use(checkwell use):
Ms REEK':'
Water Supply Well: Mom To alAltrsl in sI orslzs THIcxATFss 1tAT1iR1AL
Agricultural 10unicipal/Public & fh ra
Geothermal(Hesting/Cooling Supply) dentlal Water Supply(single) R ft. 1rr
lndustrial!Cornmercial dential Water Supply(shared) M GROUT-
FROM TO. MATERLit,.l� 6hIPirtCBM>:t�•�MbTHOD&AMOiJN'r'
__Irri ation ft.
Non-Water Supply Well:
Monitoring ORecovery IL
Injection Welft ft ft
Aquifer Recharge DGroundwaterRemediation 11SAND/GI2AVELPAGK da liable ..
Aquifer Storage andRecovery 08alinityBarrier FROM To nanTSRrA Eaol�etcEalENrMernoD
Aquifer Test I)StomnvatcrDrainage
Experimental Technology DSubsidence Control % R
Geothermal(Closed Loop) ®lTmcer 20.DPILTTwGLOG attarhadditionalsbeetsifnc
FROM TO DESCRn'T10N color bmdueM soiUmek e. irr sat.cle,
lecotilarmal(Heating(Cooling Rd=) 0ther(explaiaunder#21Remarks) O ft. p
4.Date'Well(s)Completed: ((LV Well
M 2
So.Well Location: ft ft
Farnity/Owner Name �u FacilitylM fepplicable)
00 ft.
1t' G l.�itfa.�'G -114. .— M
tL ft
Physical Address,Ctity,and Zip
i l 2L REMARKS
County Parcel Identification No.(PIN) c Sv
saErfie3s^.
in rtJ?.
Sb.Latitude and longitude in degreeelminuteslseconds or decimal degrees: `
(ifwell field,one ladlono is sufficient) Ck 22.Certification:
W
Signature afCe edwellcontractor Date
6.Is(are)the Ivel)(s) ermanent or 1OTemporary (were)constructed in accordance signing this'fomr,l herek'certify thal.the 1ve11(s)was
7.Is this a repair to an existing well: QYcs or ffNo ivWL 15A NCAC 02C.0100 or 15.4 MAC 02C.0200 i7eII Consurruloa Standards aid that a
Ifthis is a repaa•;fdl oat imonn=11 construction infonnatipfi and explain die nature ofthe eoM ofthis record has been pravtded to the well miner.
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repair under n21 remads section oron the backofdiFsfmm. 23.Site diagram or additionalwell detalls:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details.You may also attach additionalpages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTALNUMBER ofwells I.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2&7e (ft-) 24a.For All Wells: Submit this ftdn within 30 days of completion of well
Farmuddple wells Ilst a71 depths ifdifferort(example 3Cg200'oad2Q10D) construction to the following
10.Static water level below top of casing: lid (ft.) Division of Water Resources,Information Processing Unit,
Tivaterlevel is abave casing use +" 1617 Mail Service Center,Raleigh,NC 27091617
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11.Borehole diameter.,�_Ca) 24b.For Infection Wells: In addition to striding the form to the address in 24a
above,also submit one copy of this foaa within 30 days of completion of well
12.Well construction method: ro VAconsttuctionto the following:
(i.e.auger.rorniN cable,diractpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ff 1636 Mall Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 10Method of toss: 7>} 24c.For Water Supply-Al Iniecti�n 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: Ud completion of well construction toithe county health department of the county
where eonsttucted_
Form GW-1 North Carolina Department ofEavironmental Quality-Division of WatarResoutces j 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 274011
Record of Construction, Repair® ®r AbandonMent of a Well
Address of Well: 79 l� t^r� ti G InfAve, L TUDE
Well Permit Number: 2 "O 0.2mic LONGITUDE ?t-T.(90-
Well Contractor Company: Ao_&A oral Completion Date:
Total Well Depth: 21s ft. Well Yield: to gpm Static Water Level: Yo ft.
Outer Casing Material: (?YG Formation Log
Casing Diameter: �_in. Casing Depth: f2w ft. Depth ! Description
From: O ft.To:
hnaeir Coming Material: From:-IL-P ft.To:915 _ft. g=&
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: fL To: ft. From: ft.To: ft.
From: ft.To: ft. From: ft.To: ft.
From: ft.To: ft. From: ft.To: ft.
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Water Production Zones
Depth: ft. ft. ft ft. ft. fe. ft
Yield: to gpm gpm gpm gpm gpm 1' 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: Y Certification#: y11e%6 Date:�%2�/-�Z.-
Record of Pump Installation
Pump Installation Company: Pv Completion Date: I
Pump Depth: ft. Static Water Level: `4 D ft.
PumpVQWK.5e- `�'61'�-SQ�-J�QS� � /
Brand: � � Pump Size and Rating: � 1l� hp C) gpm
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I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on tb' tea d that a copy of is record has been provided to the well owner.
Well Contractor: Certification " Date: ZZ
Revised:January 1,2009