GW1--03539_Well Construction - GW1_20230519

WELL 1CONSTY2UCTIoN RECORD Internal Use(GV�it Print t Form
For only: —I.Well Contractor Informationt
Chris King
19.WATE
Well Contractor Name FROM R ZONES TOI DESCIt[PTLON
2080-A �0 it. Qf 1 IL 57—
NC Well Contractor Certification Number
Aqua Drill, Inc. 15.OUTERCASING formuIti esedwells OR LINER ftfa licahle-
FRO51 TO' DIAaETER THICKNESS MpATERiAI
Company Name 0 it. CK ft. ���r in. )Piz�� ! l V I L
i rJ 16.INNER CASING OR TUBING eothermal closed loo
2,Well Construction Permit#. I Lf.+f�j j� `60� FROM TO DIAMETER TmCiewss MATERIAL
Llst all applicable well construction permits(I a UIC,Cotmly,Stat4 Variance,etc.) fL ft. In.
3.Well Use(check well use): tt fL
Water Supply Well: 17.SCREEN
Agricultural FROM1i TO DIAMETER SLOTSIZE THICKNESS M1IATERIAL
Municipal/Public fL ±ft
Geothermal(Heating/Cooling Supply) ILesidenfial Water Supply(single)lndustrial/Commercial in.
Residential Water Supply(shared) 18.GROUT Irri ation
FRODI TO M1L4TERTAL EMPLACEMENT M1fETROD&AM1fOIR�T
Pion-Water Supply Well: it
Monitoring Recovery C' Zu c-
Injection Well: R• ft.
Aquifer Recharge C—undwater Remediation R• fr.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK Ra Ifcoble
FROM TO MATERIAL E6�LACEMENTMETHOD
Aquifer Test 'oStomrwater Drainage fL fL
Experimental Technology DSubsidence Control ft fL
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ` Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soWmck twIz Fmift slze ere
ft. & IBC C°
4.Date Well(s)Completed: � ` 3 WeR ID# ft. j ft rK-C
ZaCc
Sa.Well Location:
1� LL ft. tL
Facility/O
wnerNaame Facility W#017appIicable-) ft, fL
G � 1 /711�a1/I uaV1) �' �QUI ✓ I,;w C IZ� % fL ;1
Physical Address,City,and Zip f4 fL
1' t.� tl-•-
21.REMARKS " v.
County Parcel Identification No.(PIPp
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lamong is sufficient)
22.Certification:
rr W
6.Is(are)the well(s) ermanent or oTemporary signature ofCethSed W'ellCowractor i
Date
7.Is this.a repair to an existing well. DYes or By signing this joint,I hereby certi•that the rvell(s)was(were)constructed in accordance
IflGis is a repair,fill oat lmoxo:well construction h formation ftaln Die nature ofthe COPY afthis retard h as0been pray ded to the 2C.02vell ot00 el/Construction Standards and that a
repalr wtder#11 rernarb section or on the backofthisfornL
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:
I►►l IY
9_Total well depth below land surface: °.J SUB TTAL INSTRUCTIONS(fL)
For multiple wells Nst all depths ifdiffereut(example.3@200'and 2@100� 24a•!or All Wells: Submit this form within 30 days of completion of well
5,_10.Static water level below top of casing: construction to the following:
Ij vater level is above casing use ,+,, (ft) Division of Water Resources,Information Processing Unit,
11.Borehole diameter:
1617 Mail Service Center;Raleigh,NC 27699-1617
Cn•)
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: !/ ) j'i above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,directpusb,ear-) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Man Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test -5
� �1 24c.For Water SunDly do Injection 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 co
tmty health department of the county
where constructed.
Form GW-1 North Carolina Department of Envimnmentai Quality-Division ofWaterResources Revised2-22-2016

I
GUILFORD COUNTY DEPARTMENT OF PUBLIC HE LTH
Division of Environmental Health,Water Quality Unit
400 W.Market St.,Suite 300, Greensboro,NC 27461
Record of Construction, Repair, or Abandonment of a Well
Address of Well:6,5-9 f Ulvcl LATiTi1DE 3
Well Permit Number:22 _ I I I-} (Z - )d `7 1 LONGITUDE
Well Contractor Company: - �'�tZ
Completion Date:�``� ' .2^3
Total Well Depth:2 5- ft. Well Yield: 10 gpm Static Water Level:
Outer Casing ,�Viatenal:ID i-2 1 ply 1e Formation Log
Casing Diameter: ` in. Casing Depth: 14157 ft. Depth Description
From: 0 ft.To: ft. R i ( I A%l
Inner Casing Material: From:—ft.To:U _ft. 5 A N a lza c
Casing Diameter: in. Casing Depth: ft. From:-L2-ft. TO.2255'"ft. u G z w ry
From: ft. To: ft.
Grout From: ft. To: ft.
Depth Material Method From: ft. To: ft.
From.. ® ft.To:90 ft. cc - t'�� From: ft. To: ft.
From: ft.To: ft. From: ft.To:—ft.
From: ft.To ft. From ft.To: ft.
Water Production Zones
Depth: '51' 0 ft. 31 0 ft. ft. ft.
Yield: 5" gpm 5- gpm gpm gpm 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 Well
Rules in effect on-this date and that a copy of this record has been provided to the well owner.
Well Contractor: �, Certification#: 0 9 d _A Date:
Record of Pump Installation
Pump Installation Company: Completion Date:
Pump Depth: ft. Static'Water Level: ft.
Pump Brand: Pump Size and Rating: hp gpm
I hereby certify that this pump was installed and wellhead completed 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: _ Certification#: Date:
Revised:January 1,2009 i I