GW1-2023-02172_Well Construction - GW1_20230306

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
S
d U�Q,, r I
aNdaisuy UUUU i 1'®a' la.WATER ZONES
Well Contractor NamAir
e
FROM TO DESCRIPTION
0S0 '' 1+C6R• )s��? ft 56 Kr Pi ih
NC Well Contractor Certification Number ft ft
15.OUTER CASING(for multi-cased wells)OR LINER(tf ap !feeble)Aqua Drill, Inc. FROM TOO DIAMETER THICKNESS MATERIALMATERIAL
Company Name 0 ft. I
: 7.:� ft. I 6:�y in. i$wz.2 l. I )')j 'I ?�
# • 16.INNER CASING OR TUBING(geothermal closed-loop)2.Well Construction Permit
G'I Y11,9/2-CO" y i FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) obsidential Water Supply(single)
R ft. in.
Industrial/Commercial
DResidential Water Supply(shared) IS.GROUT
! Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. ,.y/t ft. �,, --1 "'20C,
Monitoring Recove �c v `' '� J
Injection Well: ry ft ft
Aquifer Recharge (Groundwater Remediation ft ft.
Aquifer Storage and Recovery DSalinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IOStormwater Drainage ft. ft.
Experimental Technology 0 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,salvraek type,grain sire eta)
Geothermal(Heating/Cooling Return) / • 0 ,t. ft. tZC �. 1 lc) V
4.Date Weil(s)Completed:)2-2 7-2a ell um "ktt. ft
5a.Well Location: 35- ft J f�8!c J"•'ft I? U e i-Lia).1r c _
ft. ft. --._- .-_- • •_.,;.,
Facility/Owner Name Facility 1D#(if applicable) ft. ft. J �j
3ceo Of(i )(4)( c�' 'r�'C�L/6`efiq Jc Iry C ft. ft. n�R !� t!��LJ
Physical Address,City,and Zip ft ft.
(�t50a�L� 21.REMARKS : . i 1,.,
ounty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
N W (/
6.ls(are)the xreH(s)t Permanent or (Temporary Signature ofCert Certified Wal Contractbr Date
7.Is this a repair to an existingwell: By signing this form,I hereby certh*that the well(s)_was(were)constructed in accordance
Yes or o with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under fill remarks 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 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:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths IfdBerent(example-3(,200'and 2@100) ons c
(fL) For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:
(R) Division of Water Resources,Information Processing Unit,
II-water level is above casing,use"+':
/- 1617 Mail Service Center,Raleigh,NC 27699-1617
- 11.Borehole diameter: 6 (in.)
24b.For Infection Wells: hi addition to sending the form to the address in 24a
12.Well construction method: ► cd jZ� ) above,also submit one copy of this form within 30 days of completion of well
0.e.auger,rotary,cable,direct push,etc.) construction to the following:
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FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
} 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �ld Method of test: 1'}1' 24c.For Water Supply&Infection Wells: In addition to sending the form to
13b.Disinfection type: the address(es) above, also submit one copy of this form within 30 days of
Amount: 0/ completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016

GUILFORID COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W.Market St., Suite 300, Greensboro,NC 27401 •
Record of Construction„ Repair, or Abandonment of a Wen
Address of Well:_3%-,0 a)el We'e' e 4 5-46 Ye�cl 7)e ),n.1 !C LATITUDE 3
Well.Permit Number: -o c.) X}IN}I 2- 0_ .y c S-- LONGITUDE
Well Contractor Company:j'J C 0 IA r)r; )) Completion Date:/2 - 2?- 2.-2_
Total Well Depth: ) C,'S" ft. Well Yield: S 0 gpm Static Water Level: 5 C) ft.
Outer Casing j Material: , LAC SD IL 2 ) Formation Log
Casing Diameter: . in. Casing Depth: 43 ft. Depth Description -
hazer CasingFrom: 0 ft.To:6 ft. 7 r A ( I»y
Material: . From: (., ft.To:3S' ft. Sl•1 vuci fe,cc,
C.
Casing Diameter: in: Casing Depth: ft. From:3,S' ft.To:1 SS:ft. I3lu c (czn Yu i-)e.
From: ft.To: ft.
GroutFrom: ft.To: ft.
Depth Material Method " From: ft.To: ft.
From: 0 ft.To:2 C1 ft. et men)--- f u61C From: ft.To:
From: ft.To: ft. ft
From: From: ft.To: ft.
ft.To: ft. From: ft. To: ft.
Water Production Zones
Depth: )2c ft. ft. ft. ft.
Yield: gp mft. Ft. ft.
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 iri effect on this date and that a copy of this record has been provided to the well owner.
Well Contractor: ems/�ly Certification 0
/�� #: � ` 0 iq Date:)2 ,2 7`.2-2-
nacord of Pump Maitallila2rion
Pump Installation Company:w 1 ct-�- i ‘ -
i Completion Date: `3 i 1/ 3
Pump Depth: I ) ft. Static Water Level: 4-4 v ft.
Pump Brand: -0 Ouot -2_ 9 01 rY\-i —ea D S O`7 Pump Size and Rating: 3/4 h /0
I hereby certify that this pump was installed and wellhead completed according to the Guilford Count Well gpm
Rules in effect on this date d that a copy f its record has been provided to the well owner. y
Well Contractor: ail 4 Certification#: r1 . Date: 3 - 2-
Revised:January 1,2009