GW1-2022-10821_Well Construction - GW1_20221209

l Pr inUp M.•. :.•
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
L Well Contractor Information:
i ,
FROM TO DESCRIPTION
Cameron Bazin I4:wazERZON$s. " '
weltcontractorName IRStt it
4518-A ft it
NC Well Contractor CeMcation Number I&OUTER:CASINC'fosmuld_cssedivdls ORLTNER tfa limtite _ '.r•
Aqua Drill,Inc. FROM TO DIAMETER THIMMS MATERIAL
ft. o it 7n.
CompanyNatne INNER CASING G.'ORTUBIN "ebtherrulddosed-fe "-
2.Well Construction Permit#: Z!i'y • LA/ 2� 0,( rxoM TO DIAMEreR THIc[a�tFss
List all applicable imll cmatraeffon permits(I.e.Wr_Cotarry,Stale,Vari—M etc) ft
ln.
3.Well Use(check well use): 17. ft, ft sn•
Water Supply Well FROG!SCREEN"
O DlAM6T i SLOTS72E iHICfn�SS ftATER1AL
Agricultural $R=ip
llPublic ft. TaGeothermal(Heating/Cooling Supply) at vJaEer Supply(single) R jt is
Industrial/Commerciat Re-s➢dential Water Supply(shared)
18.GROUT ".• ..,.. .. �-. � ,
hri at10n FROM I To MATERIAL F.MPLACEMENTMEMOD&AMOUNT
Non-Water Supply Well- 40 ft. U .It
Monitoring ORecovery
Injection Well: % fy
Aquifer Recharge OGrotmdwaterRemediation
I9.SAT!iDIGRAVELFACR amppitcabie . - "
Aquifer Storage andRecovery OSalinityBatrier FROM To IMATERTAL'" EMPLACEhfENrM�THOD
- Aquifer Test o t numaterDrainao O- ft
Experimental Technology ElSubsidence Cont of a. It.
Geothetmal(ClosedLoop) EiTracer 20:D12ILL11VGLOG attach additionalsheets'ifnecess -MGM "
• TO Geothelmal(Heating✓Coolin Return) Other(. lainunderMIRemarks) 40 ft it ft ar scluerroN(rotor.nnraness sv;0ro ektaz,tn etc)
4.Date Well(s)Completed: 2 1i`e01DR ft ft ,
et ft
Sa.Well Location:
Facility/OrvnerName FacilitylDv(ifappGeable) D' t its i Vs-~
7423 1,;J±14 &JA&TG G,., ft ft
ft
Physical Address,city,and zip ft.
/� __ Weor& 2_O Z1.REMARKS --: 'c^1 i�i(*G=.� F: l.R.l
���t E)VJQ130G
Ce unty Parcel IdentificarionNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(fwell field,one Wong is sufficient) 22.Cerd ication:
6.Is(are)the well ..Permanent or MTcutporM7 Signature ofCertified Wen Contmctar DtgF
By signing this form,Ilmreby certiyy that•tire rvell(s)was(xere)wmlmcted in a rdmce
7.IS this a repair to an existing�ve8: , Yes o No svid,ISA NCAC MC.0100 or ISANiZAC 02C_OZOO WeR Constaicdon Standards mid drat a
lfdris is repnfr,fill otRknoaa Hell covstnredap injormatro and explain dte nohae ofthe cagy oJthis record Iras bees provided to the well mvner.
repair under 021 rw:aris secffcn or an die back ofthisform. 23.Site diagram or additional well details:
S.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 I GW-1 is needed.Indicate TOTALNUMBER of wells construction details.You may also attach additional pages ifnecessary.
drilled SUBMITTAL INSTRUCTIONS 1
9.Total well depth below land surface: 2 2, (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wens list all depths ifdiffereni(example-3@200'and 2@1001 construction to the following.
10.Static water level below top of casing: (ft) Division of water Resources,Information Processing Unit,
lfrvaterlevel is above casing.vse"+� 1617 Mail Service Center,Raleigh,NC 27699 1617
1 !
11.Borehole diameter. (in) 24b.For Iniection Wells: In addition'to sending the form to the address in 24a
(e,(A above,also submit one copy of this,form within 30 days of completion of well
12.Well construction method: coustructionto the following:
(i.e.auger,rotary,ruble dirntpush,etc.) !
Division of Water Resources,Underground Injettion Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2,0 Method of test; ///!Ale 24e.For Water SUDDIV.&Iniectiol Wells: In addition to sending the form to
Jf the address(es) above, she submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed-
Fort GW-I Narth Carolina Department of Eavimmnental Quality-Division of WaterR.esowces Revised 2-22 2016

GUILFORD COUNTY.DEPARTMENT OF PUBLIC HEALTH-
Division of Environmental Health,Water Quality�Jriit
400 W.Market St.,Suite 300, Greensboro,NC 27401
Record of Construction® RSPB!r, or Abandonment of a well
Address of Well: I!Ae, I 3rrLAl0, l
�?Il
Well Permit Number: 2�7_toy` W&AR-0 230A LONGITUDE Y)
Well:Contractor Company: ADx a AN Completion Date:_1I 9.-y
Total Well Depth: 2 2-5 ft. Well Field: 2-0 gpm ' Static Water-Level: y0 ft.
outer cas-mg Material:1 VG Foalhatimn log
Casing Diameter:�_ in. Casing Depth: t?o ft. Depth Description'
From: -O ft.To: L1,9 ft. 0,4,V
ftnea•Csdng Material: Fi ore: Uo ft.To:
22 4 f>» Qar�1i
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-,—ft.To. I ft.
From: ft.To: ft. From: ft.To: ft.
From* - ft.To: ft. From: ft.To:
Water Production Zones
Depth: � ft.
Yield: ?o "gpm gpm gpm gpm gpm gpm gpm
Method of Repair:
Method of Abandonment:
I hereby eertify.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: ��-
�zf Certification#: �S;i'� Date:
Record of Pump gnstappatlon
Pump Installation Company: -! ,< c Completion Date:
Pump Depth: ft. Static W er Level er ` ft.
Pump Brand: 471 o�'� _ -�-�'�ps17 ump Size and Rating: I 0 li gp m
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect o date d that a cop of this record has been,provided to the well owner.
)j W ell Contracto : Certification Date:
Revised.January 1,2009.