GW1-2022-00200_Well Construction - GW1_20221216

Part Farm
WELL CONSTRUCTION RECORD(QW 1) For Internal Use Only: -
1.Well Contractor Information:
Chris King 14.WATERZONES i
WellCormactorName FROM TORIPTION'
2080-A Aot• '9�41
0ft.
NC Well Contractor Certification Number
15-IOUTER CASING for multirdsed:Welis OR LINER tf a licable
Aqua Drill, Inc. FROM TO DI.AnIETEW THICKNESS MATERIAL
Company Name
Q It 7S-
n q
16:INNER CASING OR TUBING.(eothermatcrosed loo
2.Well Construction Permit#ZU (Gi_[`4 N►4 R e)Q© i(I FROM TO DIAMETER% TIUCENESS MATERIAL
List aU applicable well construction perm—its q.eCrIC,Coanry,State,Variance,etc) rt ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER. LOT SIZE THICKNESS MATERIAL
Agricultural ( MunicipaUPublic ft ft in. t
Geothermal(Heating(Cooling Supply) sidential Water Supply(single) tt g, in ;
Industrial/Commercial F31tesidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLA EMENT METHOD&AMOUNT
Non-Water Supply Well: ft '.20 ft.
lie
_ Monitoring 1�_:Recovery M ft.
[IAquifer
on Well:
Aquifer Recharge a fr. ft. j
g DGroundwaterRemediation
fer Storage and Recovery �'}Salmi Barrier. 19 SAND/GRAVEL PACK�fe livable
r_1' tY FROM TO LIrATERIAL' E1rIPLACEaaNTpIETHOD
Test oStormwater Drainage ft ft
rimentaLTechnology E3SubsidenceControl ft. fthennal(Closed Loop) Tracer 20-DRILLINGI, attach add.1tional'sheets if necessary'hermal eatmg/Co0ling Return) 00ther(explain under#21 Remarks) FROM To Q R DESCRIPTIONDESCRIPTIONcolor,darQnets sorvrock a rain size eto fr. I
4.Date Well(s)Completed:12- Weimif ft t
ft J' C
Sa WellLocation: ft t, f 1
ft. ft
Facility/OwnerName Facility ID#(if applicable) rr• ft
-•r:. r s•�sue,.
Physical/Address,C tty,and Zip atr, 27 , ft rt
1`761 /Sl' 21 REMARKS — j _
County Parcel IdentificationNo. P
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: is r fl
(if well field,one lat/long is sufficient) 22.Certification:
N WR/L'� 2——f z
Si turn of Certified Well Co for ate
• 6.Is(are)the well(s' Permanent or Temporary » Date
B3'siguing this form,"1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EJYes or To with 15A NCAC 02C.0100 or 15ANCAC;02C.0200 Well Construction Standards and that a
Ifthis,is a repair,fill out known well construction information and explain the nature ofthe copY ofthir record has been provided to the well owner.
repair under#21 remarks section or on the back ofthir 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:
SUBMITTAL INSTRUCTIONS
��
9.Total wew 3
depth below fond surface: (ft) 24a.For All.Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijd fferent(example-3Q200'and 2Q100� constntction to the fallowing:
3a
f Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,ljwater level is above casing,use"+" g t,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (O (in.) 24b.For Iniection Wells: In addition tto sending the form to the address in 24a
12.Well construction method: t f above,also Submit one copy of thisi form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,e construction to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Matt Service Cent ,Raleigh,NC 276994636
13a.Yield(gpm) /1� Method of test:'S) 24c.For Water Supply&Injection Wells: In addition to sending the form to
D the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to i i 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

1
I
II
GUILFORD COUNTY DEPARTMffiNT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W.Market 3t.,Suite 300, Greensboro,NC 27461
Address of Wel1:� �3 � _
��S�s,a 9 a_n) LATITUDE S_
Well Permit Number; _ - S3 o �'� 2723r-3
LONalTubE
Well Contractor Company: Z`
Completion Date:
Total Well De the �� C�
P 6 , ft. Well Yield: gpin Static dilator Level: 30 ft.
Omteir C25hag Material:5a 2 ��tir C Foramat� tn Leg
Casing Diameter, % ®>
in. Casing Depth:�_ft. Dept Descri tion
From:�?_ft.To:� { ft,
I'CiwetP Caaing. Material: From:_!�6_ft.To:�ft..
Casing Diameter: in. Casing Depth: ft. From. U ft.To:3�_ Sift. U L C;zar, �P
From: ft.To: 1 ft.
Grout From: ft.To: ft.
. DepthMaterial ethod From: ft.To:
From ft.
:! ft.T..�® ft. d -,� From: ft.To.-From. ft.To• ft. ft.
From: ft.To: ft, From: ft.To: ft.
----____ From ft.To• ft.
W2'0er°PrOducid(DIM Zones
Depth: 2LO ft. ft. ft. ft. ft
Yield: �gpm m ft. ft.
�m aPm SPm ____gPm gpm.
Method of Repair:
Method of Abandonment
I hereby certify that this well was constructed,repaired,or abandoned according to the Guilford County We]I
Rules id effect on this date and that a copy of this record has been provided to the;.well owner.
Well Contractor: r - 1:
Certification#: Date: -
ecolyd 07 PUMA iF
Pump Installation Company: C
—1- — Completion Date:
Pump Dept11 r ft. Static Water Level: 140" ft•
Pump Brand: ti MS 10 5 l` l
Pump Size and luting: hp ) gpm
I hereby certify that this pump was installed and wellhead completed according to'the Guilford County Well
y Rules in effect on this date an that a copy of this record has been provided to thel well owner.
Well Contractor. ,
Certification#.1 . Date:.._
Revised:January 1,2009