GW1--04432_Well Construction - GW1_20230710

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only L Print Form
1.Well Contractor Information: I
David Belcher 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
4594-A 90 ft' 901 ft• 15 (}4 (Fran iAt )
ft. ft.
NC Well Contractor Certification Number
IS.OUTER CASING(for multi-cased wells)OR LINER(if ap !feeble)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 7n It (I/46 5 ►n' STIR 0I I PVC,
/�nd 16.INNER CASING OR TUBING(geothermal closed-loop)
t7i
2.Well Construction Permit#: •09-(j)t)H -t�p(o,5 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC Count State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ° unicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) igiResidential Water Supply(single) ft ft in.
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ' 093 ft &m e fj{- (ati 6,14h ID IC 16
Monitoring °Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge '°Groundwater Remediation
Aquifer Storage and Recovery Salini Barrier 19•SAND/GRAVEL PACK(if applicable).
tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stormwater Drainage ft. ft
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,sail/rack type.grain sae.eta)
Geothermal(Heating/Cooling Return) JOther(explain under#21 Remarks) 0 ft, 0/Q
Cla
4.Date Well(s)Completed: (0-cat.83 Well ID# o90 ft. 65 ft AU(JI
5a.Well Location: 6.5 ft 7O ft }�t^I CtrQO i{6
Char) 'Deal 70 ft. IZ'5 f` (Phie C-ccrnl
Facility/Owner Name Facility ID#(if applicable) ft, ft.
•
jal ga FraPmef Ptidl lunar,/Al( ,27a s5 ft. ft. - f,,-,,f:r 1 ..'
Physical Address,City,and Zip ft ft '' °w ..a ''
h 21.REMARKS III 1 e 2023
Cyl11-�Or� /_ i v
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: In;L;cr".:e.l^ i�t'•. ':,.,.1 (�t$i
(if well field,one lat/long is sufficient) 22.Certification:
850 51(' 54.wet N 79° SG' 51.c)rr W �� 3
�ceD -
6.Is(are)the well(s) Permanent or °Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the u+e1l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or No 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 stature of the copy of this record has been provided to the well owner.
repair under 021 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: - II W5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: yQ (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
�(y A n�i above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of tesh (r 4 CY)14.11 the 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1-111-1 YCP/O Amount: 1(opz 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 PU1311C HEALTH
Division of Environmental Health,Water Quality Unit
ry� 400 W.Market^St.,Suite 300, Greensboro,NC 27401
lacord of C1 C® Jlyrl�3ctri©llb RepaNr© or Ab indoniml1i+�, ®f a Wall
Address of Well: (019,2 1'elAccileC q81 l'ullan 1`JUr.,-P269 3 LATITUDE 3 5 513' 54 . Si
Well Permit Number! (9,? -oa•L..)04-00075 LONGITUDE 79 3Co' 51 , O
Well Contractor Company: r r)r;ll Inn. Completion Date: 6• ac1. 9.2)
Total Well Depth: I ft. Well Yield: 15 gpm Static Water Level: ye) ft.
Inter Casing Material: (l VC Formation Log
Casing Diameter: c .a5 in. Casing Depth: 70 ft. Depth Description
From: 0 ft. To: 40 ft. any
Inner Casing Material: From: 020 ft. To: Cos ft. M
ug
Casing Diameter: in. Casing Depth: ft. From: 65 ft. To: 70 ft. (1)kue Ctc(w1\.
From: 9O ft. To: Ig5 ft. %1up ac e.
Grout From: ft. To:
ft.
Depth Material Method From: ft.To: ft.
From: 0 ft.To: 0�3 ft. Cernerrl- 9)cx►c w'rkhTucli From: ft.To: ft.
From: ft.To: ft. From: ft.To: ft.
From: ft.To: ft. From: ft. To: ft.
Water Production Zones
Depth: 90 ft.. ft. ft. ft. f- t.
ft. ft.
Yield: )6 gpm gpm gpm gpm -gpm .gpm
gpm
Method of Repair:
Method of Abandonment:
•
• II 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: atazecel . Certification#: L1594-X Date: G.arn.ag
l=•xil�+afr.r:-a.u:a.�.�;:.•�w:�.s.:.�Gi_+--•s.. ;,-_..n.�>•�=":^ :....:•:+.... _� ...r. . .. _
a:...,..-. �ihwecr_•r'' :,.•f,_�,,,p��e��-•..•���s"".�i 1e,
Qc com`l of pump Enstanation
Pump Installation Company: t-e:0-1 DA \.\ , _ Completion Date: ~713 14:).--3
Pump Depth: l ©('2) ft. Static Water Level: 14 O ft.
Pump Brand: -1--k,c,•,�c e� l a 111-1 rl O ]Pump Size and Rating: 3!t I hp l D gpm
I hereby certi that thi lump was installed and wellhead completed according to the Guilford County Well
Rules in effect on t '• dae a that a c of this record has been provided to the well owner.
f i
Well .Contractor: ' 'II Certification#: acij-NDate: Ill.` aJ-
Revised:January 1,2009