GW1--05173_Well Construction - GW1_20230818

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WELL CONSTRUCTION RECORD WW1) For Internal Use Only:
I.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A 1{ ft. � �rt. � (9-e rr )'"l
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. 9 0 ft. 6 5,e/in. i if a g 6,4)1/
.� �y , ff 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#:.,") "Li.G '[s3 itF,!tt/Z —Cif'i 7a FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well cotrstruction permits(i.e.UIC,Coway.State,Variance,etc.) R. , ft. in.
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN
A Cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
t;n �Municipal/Public ft. R. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. ia,
Industrial/Commercial OResidential Water Supply(shared) IS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 0 fL d e)til._�,I��1" / .c/i�
Monitoring Recovery ft. ft. � 7z
Injection Well: ft. ft.
Aquifer Recharge *Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Battier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage ft. ft.
Experimental Technology IOiSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color, es,,toll/rack type.grain eke.etc.)
— C.) ft. EEcrss f'I9h
4.Date Well(s)Completed: I —.7d Well Il)# 6 ft. 6 S"fr. S 14 yj 'Zack - fv+ v d
5a.Well Location: 6 S fL , 2 rft. 13 l .Id- 4 iz Am
�� �� 1�� ft. ft. [`‘t u i v
Facility/OtvnerName Facility 1Db(if applicable) ft. ft.
S 7o e k ie ci,\Devil, i�2 ft. ft. �+UG i �a�3
Physical Address,City,and Zip C 272 �a ft. ft Ir tvn.14i ri 'r am el$Lrf
21.REMARKS r) 1-_,.' kX;
(s•SS b ) FC jZ C
nty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minuteslseconds or decimal degrees:
Orwell field,one lat/long is sufficient) 22.Certilic tion:
N W C� -v3 fi�e. -
6.Is(are)the well(srmanent or DTemporary Signature of Certified Well Contractor] Date
By signing this fans,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or lilt i.o with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jul out known well construction information and explain the nature of the cop;'of this record has been provided to the well owner.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/1DPT 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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
a
9.Total well depth below land surface: @ Se" (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@I00') construction to the following:
10.Static water level below top of easing: 3 0 (ft.) Division of Water Resoarces,information Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 29699-1619
11.Borehole diameter: 6, (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: AI tz dizi. ) 1, above,also submit one copy of this form within 30 days of completion of well
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 29699-1636
13n.Yield(gpnl) ) Method of test: ' ;9 J( 'j 24c.For Water Supply&Injection Wells; In addition to sending the form to
-I- the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: )' l W Amount: 9 O Z completion of well construction to the county health department of the county
where constructed.
i
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit;
400 W.MarketSt.,Suite 300, Greensboro,NC 27461
Re©trc i of C s nstrauctli&imp Repariri, or Ab-m®c}linnc nt ®f a Welll
Address ofWell:`5-7O3 C"pble Kurat,-! rV 'jvY or)IN, VJsCLATITUDE 3
Well Permit Number: 93 ._G2 -CAA)(f jZ- 60 f Z % LONGITUDE
Well Contractor Company:��� ��'
)) Completion Date: il -I - 23
Total Well Depth: l'' S S ft. Well Yield:
gpm Static Water Level: 7 63 ft.
Outer Casing Material: f�•-,q)i., Formation Log
Casing Diameter: in. Casing Depth: 7 0 ft. Depth Description
From: O ft. To: 6 ft. I ccl C I A y
Inner Casing Material: From: 6 ft.To:63- ft. 5(1)v4 PZ6r-e- i^n:3 d Casing Diameter: in. Casing Depth: ft. From:65- ft.To: 1¶i . ft- /'l u,e /z.ti N i l c
From: ft.To: ft.
Grout From: ft.To: ft.
Depth Material Method From: ft.To: ft.
From: C) ft.To:,26 ft. C in e j 4.. Trio C.k_ From: ft.To: ft.
From: ft.To: ft- From: ft.To: ft.
From: ft. To: ft. From: ft.To: ft.
Water Production Zones
Depth: 1 S—ft. ft. ft. ft. ft. ft.
Yield: )5" gpm 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: e�`.'.„-; Q C3 ° -
State Number: Date: c�') -/
Record of Purirop rtns a atgorn
Pump Installation Company: A , D17 1 1-t
�� I' Completion Date: F �1�;�
Pump Depth: 1 0 ft. Static Water Level: 44D ft.
LAPump Brand: -�4gc.� _b ' �I 5h�-vikc
T.- 'r - 5,).-_pioso5 Pump Size and Rating: lick, hp !( .gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on thigh' .ate anti iat a copy of/s cord has been provided to the well owner.
Well Contractor: - _) ► G
ir
State Number: 2-7,6"Date:ff/77 Z