_Well Construction - GW1_20230310 (36)

WELLCO1�tST2UCTI0I�T RECORD(G�V-1) Print Form ,
For Internal Use Only:
1.Well Contractor Information:
Chris King
14.WATER ZONES I ,
Welt Contractor Name FROM TO DESCRIPTION
2080-A CIIpS'f`- 96 ft. C 16.0), Yh
NC Well Contractor CcrtificationNumber r D" ft' t p2 r 6,Pi m
Aqua Drill, Inc. IS.OUTER CASING(for multi-cased wells)ORLLYER(ifap linable)
FROM I TO DIAMETER THICKNESS THICKNESS MATERIAL
Company Name CO ft. 1C—�7 ft 1 6/c/ in. t :C
2.Well Construction Permit#: 16.INNER CASING OR TUBING al'oe,11 iv/ i
(geothermal closed-loop)
U-� 'fir t(k)j/f' .-d29.92 FROM TO DIAMETER. THICKNESS MATERIAL
List all applicable hell construction permits(i.e.UIC,County,State,Variance,etc) ft f. In. �'
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN,
gritailtntal FROM TO DIAMETER SLOT SIZE THICKNESS. MATERIAL
°MunicipaVPublic ft ft. in.
Geothermal(Heating/Cooling Supply) INtesidential Water Supply(single)
Industrial/Commercial in.
°!Residential Water Supply(shared)
Irrigation 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery ft. -;(l� ft. lr� � � /t���/
r�
Injection Well: ft. C
Aquifer Recharge DGroundwaterRemcdiatjon ft ft.
Aquifer Storage and Recovery °Salhrity Baer 19.SAND/GRAVEL PACK(if applicable)
FROM TO hATERIAL EMPLACEMENT METHOD
Aquifer Test °Stonnwater Drainage ft. ft
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sotu[oc&type grain size etc.)
Geothermal(Heating/Cooling Return)
4.Date Well(s)Completed:3*I LS Well ID# 1-k(3- 5— 6 ft. Sty ft SIB 1'tid IZa c,�
Sa.Well Location: SO ft" S-ft. de-
•
6-rZigw)-1e
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ,+ ft ft
?goo Loki c Gbt04.c t KJ 6 ererv51a�i20 r t C ft.
ft.
Physical Address,C' ft. ft f
City,and Zip �'7�o Ls, �"�„•'•
..re___:f!j©Fc6 ! 1 21.REMARKS ,5 t o y
ounty ,,,, n 2023
Parcel Identification No.(PIN) •
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `D'''''ix:C':'.0 Ps+' ?- i td.`X
(if well field,one let/long is sufficient) r a `� `tx
22.Certification:
n w ae;
6.Is are the wells Re -"�Is(are) ( Permanent or °Temporary Signature of Certified Well Con ctor Date `�
7.Is this a repair to an existing well: °Yes or °No By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA If this is a repair,fill out known well construction it formation and explain Ste nature of the copy of this record has NCAC 02CObe en provided to the well owner Well
Construction Standards and that a
repair under#2i remarks section or on the back of this form.
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMI'CrAI.,INSTRUCTIONS
9.Total well depth below land surface: •
b'and (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
Formultiplewellslistalldepthsifdiferent(example-3(a�2t)
construction to the following:
10.Static water level belowtop of casing: 90 ,
If water livens above casing,use o (ft.) Division of Water Resources,IDlormation Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. C (im)
•
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: jr�Z ��j I above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
rl 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ,( 0 Method of test:511( 1,1+ 24c.For Water Supply&Injection Wells: In addition to sending the form to
13b.Disinfection type: KT the addresses) above, also submit one copy of this form within 30 days of
Amount:9 Q Z. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-DivisionofWaterResontces Revised 2-22-2016
II

•
GUILFOI2D COUNTY DEPART VENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W.Market St., Suite 300,Greensboro,NC 27401.
.Address of Well:—2Li 0,0
C e c LATITUDE S
Well Pennit Number: .� -O(j_ S Z ^� C�a
Well Contractor Company: LONGITUDE
Completion Date:
Total Well Depth: ft. Well Yield: '
Outer Casinggpm Static Water Level:�_ft.
Material: a ( r'i 1z
Casing Diameter: c— in. Casing Formation Log
b Depth: ? _ft. D �h• ep Description
Inner Casing • Material: From: C� I{. To: 6 ft � I v
To: _ft.
Casing Diameter:
---__ in. Casing Depth: ft. From: _ft. To: t.
From: ft To: �� ��
Grout
ft.
Depth From: • ft.
From: Q Material Method ' From:
From: ft. To: ft. cue .. Zv From: ft. To: ft.
To: ft. $.To: ft.
From: ft To: From:
ft. ft. To: ft.
From: ft.To: ft.
Depth: IV
Water Production Zones
Yield: gpm _ ft. ft. ft.
gy gpm g m ft. ft
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
Rules in effect on this date and that a copy of this record has been provided to the well owner. Well
Well Contractor: `
State Number: 0 ', Date:22
Pump Installation Company: % l -;
Completion Date:Pump Depth: D ft. Static Water Level:
1`.
Pump Brand: a171--\Sot PI 0505P
Pump Size and Rating:
I hereby certify that this pump was installed and wellhead completed accordingb hp��pn�
Rules in effect on this date and that a copy of this record has been provide the well the w Guilford County Well
Well Contractor: . �
State Number: tQ " Date: — — �