GW1--03050_Well Construction - GW1_20230310

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: Print Ft)rm
iriF`r
1.Well Contractorinformation:
Chris King
14.WATER ZONES t
Well Contractor Name FROM TO DESCRIPTION
2080-A 166 fr. /E/ ft Ya I K, 1 + ,("1
NC Well Contractor Certification Number rt. ft.
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)ORLINER(If ap licable)
FROM II TO DIAMETER THICKNESS MATERIAL
Company Name CD Et. 1 J 1 S—ft 6 l(9. in. 50 R-Z i f'� r c
��y] 16.INNER CASING OR TUBING(geothermal closed-loop) I`t`J 1
2.Well Construction Permit#:e' "G C( lU 11 P O25O( FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction penults(Le.UIC,Cotutty,Stag Variance,etc) ft ft In.
3.Well Use(check well use): ft. ft in
Water Supply Well: 17.SCREEN
gricult IIaI FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) / ,Residential Water Supply(single)
Industrial/Commercial fr in.
Residential Water"Supply(shared} M.GROUT
Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery 0 f t. 2'0 ft' GM di(� //Z tl C fC
Injection Well: ft ft.
Aquifer Recharge °Groundwater Remediation ft. ft
quifer Storage and Recovery Salinity Barrier 19.S�/GRAVEL PACK(if applicable)
FROM TO RiATERiAL. EMPLACEMENT METHOD
quifer Test oStormwater Drainage ft. ft
Experimental Technology 0Subsidence Control ft. it
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheds if necessa y)
FROM
Geothermal.(Heating/Cooling Return) Other TO DESCRIPTION(color,hardness,(explain under#21 Remarks) ens,son/mektype,grain size,etc.)
O ft ged C f61y
4.:Date Well(s)Completed: "� Well ID# �-L fr. ft /'
5a.Well Location: i/0 fr. a C/c n: 5/v c &z)N(le
ft. ft.
Facility/Owner Name / 1 +Facility 1D#(if applicable) ft. ft.
7</7 ht fi C C'I k3 4-C"' h r i 6 P e ertfc.br)� ft.
ft. `
Physical Address,City,and Zip �` �, .,°e= : 't•'1 t+
gC, 2 7c-/09 ft. ft.
i TatZC' 21.REMARKS ILAIVIAR 1 t, 21123
County Parcel Identification No.(PIN) •
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: { t? :6=;� �i1 t:`:.� .::; .,.�
(if well field,one lat/long is sufficient) t- ,Tes,:: t-z,:
22.Certification:
N W
- F? � 3
6.Is(are)the well(S permanent or Temporary Si goarnre or c embed well Contractor J g.Date
g this form,I
certi:6,that the
)
7.Is this a repair to an existing well: Yes or,Cl�itlVo withtISANCAC 02C.0100 or IS.4 NCRC 02C.020(0 Well Construcconshucted in tion Standards and that ea
If this is a repair,fill out known well construction informatio and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or ms the back of this form.
23.Site diagram or additional well details:
8.For Gebptobe/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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
I g SUBMTPI'AL INSTRUCTIONS
9.Total well depth below land surface: '"'i1
For multiple wells list all depths ifd fferent(example-3@200'and 2QI00) ons
a.
c
4 (fk) For MI Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: (�)
If water level is above casing,use"+ Division of Water Resources;Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-I617
11.Borehole diameter: 6 (111.)
7 246.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /1C %�/�! 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.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I) Method of test: t('f rl - 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: completion of well construction to the 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

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W.Market St.,Suite 300, Greensboro,NC 27401
i
•
Record of Cfnutraocitiony Repair, orAbandooll 0ant of a Weill
Address of Well:, ?` 7 C9/7 '-fife c % 14-e L LAtITtIM 3
• Well Permit Number:( -Oct-4.1IU H I4, .0,,256 I LONGITUDE —
Well Contractor Company:,i40 z)cg t'1 I Completion Date:,2 -
Total Well Depth: ft. Well Yield: 30 gpm Static Water Level: .30 ft.
Outer Casing Material:) IR-2
��i ) C. F®�uati®l, Log Diameter: �)/_ in. Casing Depth:_i i S ft. Depth p Description
Inner CasingFrom:() ft.To: ft. K e d (' n ?'
Material: From: `6, ft.To:.I J O ft. 141‘;�( i a
Casing Diameter: in. Casing Depth: ft. From: O CC
1 i ft.To ft. . ?.v c C';t_F1ru ��
From: ft.To: ft. •
Grout From: ft.To: ft.
Depth Material Method • From: ft.To: ft.
From: () ft.To: C) ft. dew Pik 4 '�i7 f s r
From: ft. To• ft, Prom: ft.To: ft.
From: ft,To: ft •
From: ft.To: ft.
From: ft.To:_ft.
Water Production Zones
Depth: /�O ft. ft. -
Yield: .�� gpm gpm ft' ft. ft Ft
ft.
gpm gpm gpm m
gP 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: ���� - .,.
Certification#4,11V. ILI Date: -
11.0
Recfcrd ©f Pump Ene ana2l® � � _ .u_
Pump Installation Company: A` l,t-Ci. b,,,•, If _ .r
lJ ) Completion Date: 310 0 c:1- •
Pump Depth: ft. Static Water Level: _ 5
ft.
Pump Brand: iou.._, 0 S5P Pup
m Size and Rating: It /
I hereby certify that this pump was installed and wellhead completed accordingord
pgpm
r Rules in effect on this date and that a copy of this record has been provided to the el owner.. County Well
Well contractor. , p'"J,12 1/7 , e_
Certification#: Date: 2
` l .3
Revised:January i,2009