GW1--07932_Well Construction - GW1_20231208

•
- •WELL CONSTliUOTIlON. OOY�(GW4): - • � ' . • .. : - -
F.
or Internal Us•e •
Only: - -
• . ' .1.•Well Conti Information: - . '
- Chris.King :.. .
:- Well Contractor Naine- - ..
14.-WATER ZONES -- -
• - . • • • - FROM' - - .TO ' DESCRIPTION.
-.
2080-A': 74 ft. • ,•7 i_ fi. ( 0 • n
ft: ft.
NC.Well'CoritnactOrCertification Number • ' _
15::OUTER CASING(for multi-cased wells)OR LINER-(if'ap"licable) -
AgUa brill,-INC.. '. : FROM • : • 'TO• " ' . DIAMETER' , . THICKNESS. .- MATERIAL •• , • •
Co:rpa ri N ne: :.- • . ' •• - �'�•ft. ft.: 7 y in.
•. • ••Lrg . f . 5ii1R21: • Af/Ic_.
^'� / 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Consti•liction Permit#/�.• `O.l '(mot,. ••7 L • -jrO3( FROM TO • DIAMETER -. .THICKNESS .MATERIAL •
Ltst all apjoh'alde well consn•ttction permits(i.e.:UIC,County:State,Varimlce,etc:) • ft.. • : ft.. • In:
' 3.Well Use(check well use): .' : • ' . • it. ft. dri..
- Water Supply Well:: . . . - . - •
A tt idtural •FROM •. •TO - . •' .DIAMETER SLOT SIZE. • THICKNESS -MATERIAL
- •
OMunicipal/Public _: • .ft: --• 'ft. in:
Geothermal(Hoating/Cooling Supply): Rcsidcntial Water.Supply(single) ..-it. -ft.' i - • •
n
Irid u;t ri al'Commcrc ial
Residential WaterSupply(sliarcd) • � •• •. 18:-GROUT.• �. . • '. � •
Ir ta.it on FROM - -TO - - -MATERIAL •• ,EMPLACEMENT METHOD&AMOUNT
NOn-yatier Supply Wel}:; ,- .• :' :
•: •©,Monitoring , : . DRccovcry it. •-
ft.
injection We1L
�quifcr:ltecharga • • .. ft: -" ft:
-, • ,JGroundwaterRentediation - ' -
x 19:SAND/GRAVEL PACK(if applicable) '
]Aquitet storage;and Recoveri ' ": Salinity Barrier :FROM 1•TO •1•'MATERiAI •F.'IPLACF,SIENT-METHOD.
Agi..i er T csr DStormwater Drainage • - ft .
l x-• : ry' .gY: OSubsidence Control .
.Eapetnneptal: zchnolo � . . : .
ft. . .
;:Geotnern al(Ciosed•Loop) Tracer 'F20R:ODMRILL INGT oL,OG(attach DadFdClH
RotnPaTli Osh"ee(ts toif,necsresnssan)so'i V.ro'LiGcerhe ral(ticating/CoolingRetum) ,rilOther(e)iplain wider#2l Remarks)
ck.typ;,ramsue ote.)
Dale Wells)Completed:1�717-13 Well ID#1 3-7.1 `�.// r�,,J .
.. fi. ft. -•
.
.�• ' /..2 � 1�rJGr 1ZoCK
Sis 1tielt t pc:aiot:: • e• it•• .. ft.•
,/ �� 13ftsto. � ,�, e ..
fr. rr. �N
. Facility IDr:(if applicable) - •t• ! • ft " . t i:,•'z 'q 1��W .
577 • .• • fL ft. '
-Pu ysical/iui.wils,:City.grid Lip. : G�G. $ ...e.3 .
6--I-E • • 11:REMARKS . • •-t7r•••--v )lip.
(vRi.Rt,t - - .. •
tI+I V,,„s- ,,1,1 t .. .
. • Parcel Identification No.(PIN)• • .. . • •D:'v�'''
,SO.Litiitade avid•longitude in degrees/minutes/seconds-or decimal degrees: • _
(if well lield;.one It/Jong is suffcicnt)• - ' •
22.Cei titici on
6.�'/7,2
6-1s(nre)he wolt(s pernianent or.OTemporary Signntnrc ufCi rtiticd'Well ContractorDue
•By signing this Arm,i hereby case that the well(c)tens'(rere):ci;muu,sied iti accordance 7•is t':b-::tea-:'-`to an existing«'ch': ' 1•es 'or . _7 •uitl{/54 +`C'C 0?C:w on or!SA NC'4C Ii2C.0200 tie/I Canstructirn,Siandardc and!Ng a I/thi:a�)epa r:Jill am.kris::it i:•ai/conctrartain.it f aIitulion and e-tplain the name Oldie' cctkt'itf ibis r•ccai d',Wheel'provided is the well earner: ' - '
rcpai t a• i rcaicirks set:fiail-or an the hack of this ftn`st. -
23.Site diagram ok-additional well.detailsr • ' - -
S.For Geuprobe/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
• [roil,:i.;l'i,: an l,1 GW=i'is NUMBER-needed: Indicate TOTAL NBER of wells: :construct ion details..You may also;attach additional pages jfneceSSary.
drilled:_ •V t_ SUBMITTAL.INSTRUCTIONS
9.Tot:al ur}1 death below land.surface:
Far'muliiik,,,�dclist beIopaisrfd11erfa(e,ranple:360._00•and20100') . (ft) 24a:.For All Wells: Submit this form within 30 days of completion of well '
3 construction to the following: - •
1t).Static water level belt*top•of casing:. a .• • . . .• . • . '(ft.) Division of.Water Resorirees,Information•Processing Unit,
Irtvater!ri•ci is Oor,?casing,Mt, +'•
1617 Mail•Sertiice Center,Raleigh,NC'27699-i617
I i.l=oreliole:daameter: C. (in.) �
346.For Injection Wells: In addition to sending the foim to tiie address in 24a
•
12.1:Veil constraction method: I IL. C
-above,:also submit'one copy of this form within 30 days of completion of well
(i.e.auger,rotary:cable, ptisii,etc.) construction to the following:
Division of Water'Resources;Underground Injection Control Pro am
FOR WATER SUPPLY WELLS ONLY:'• 1 ti361VIai1 Service Center,Raleigh,NC 27699-1636
13a.Yield(oprir) �i LI Method.oftest: S 1 h� 2.4c.For_Water Supply Si Iniectil n'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: //7 A Amount:9 a z . completion of well construction to the county health department of the county
where constructed.
Form GW-I NorthCarolina Department of Environmental Ouality-Division of Wnrar ua.,„,...e,.: - . ._ _- -

GUILFORD 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 Well
Address of Well: 7.2. .
q LATITUDE 3 -
Well Permit Number: �3:Y:7_? -� it1/1Z "0 0 3:4 d . LONGITUDE •
Well Contractor Company Aqua Drill,.Inc: •
Completion Dater l 7 ,
IZ ( 14•C
Total Well.Depth:�. �/5 f• t. • Well.Yield: ('� :-gp Stark Water Level: ... ..
Outer Casing 1Material 5C) 2 . . . a .
riDiameter:� / � Foxroroation Leg •
Casing _ .
.. f . in: Casing Depth:::Y%- ft
Depth Dyseription
From: 6 ft:To: 3. ft.. Jed. ( 1 t4
Inner'Casing Material:
From.;: .:ft. To. :ft, 5f1•04 tZoc lr' . :.
Casing.Diameter: in. Casing Depth` ft.. From:ca;. ft. To•I LIS ft: Jo e,
From:_ : ft. To fE.
Grout
From ft. To , •
Depth Material
ethod
. �ft
-From.: . From..:. .:ft.To �'ft: �. . . . . .
Q ft:To:AO. ft. rem eiJ)— uG(C. From
From:. . . .. . _�ft: To :ft. . . _ .
ft.To:. . ft;.
From:. . ft. To :ft:
From ft;To ft.
' • From: ft. To: _ ft;
.. . .:Water Producton'Zones
Depth. '(;) ft. :
ft. ft: • ft. . ft:
g •
� m ..
p gpm . . gpm gpm :gpm
ft
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 co of this.record has been provided to the well owner
. Chris King . .
.Contractor.:.
Well 2080-A.
Certification#:. Date: l
• Record of PumpInstallation
Pump Installation Company: 1.: r; .l �l1 �. ..
�'� t�--.• . Com .letion Date:
p 11
Pump Depth: ft. StaticOWatter.Level
17s
Pump Brand: 4 � -P T�m-1a - 3r
S � Pump Size and Rating: � .1 q hp /D gpm
Ihereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on this date and that a c of this record has been provided to the well owner:
.. .
Well Contractor:Va2' ,. - (��
Certification#::2 ` 6i9�Date:;d:24`Z I�3
Revised:January 1,2009