GW1--00317_Well Construction - GW1_20240112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: I
Chris King 14.WATERZONES
Well Contractor Namc FROM TO DESCRIPTION .
2080-A ao ft. kv. ft. M 6 ip((PI
ft. ft. I
NCWell Contractor Certification Number 15.OUTER CASING.(for mu1H-cased'wells)'OR LiNER(If ap 'feeble) -
Aqua Drill,Inc. FROM TO DIAMETER. THICKNESS MATERIAL
Company Name 0 ft. Li'3' R. C ye 'in:. 5.p jZ 2.1 pi N'i c
r°/� /)(/� `per �7 ¢ -16.INNER CASING OR TUBING(geothernial closed-loop)
2:Well Construction Permit#: -V�C.7 cd 1 A IZ`00.16 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County.Stale;Variance,etc.) R. ft. :la:
.3.Well Use(check well use): ft. R. la.
Water Supply Well: 17.31'REEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. In:
Geothermal(Heating/Cooling Supply) . esidential Water Supply(single) R. ft. in,
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT - - -
irrigation FROM TO MATERIAL EMPLACEMENT..� METHOD&AMOUNT
Non-Water Supply Well: 0 R. elb ft.�re sett)- /i-Z U Ci�,/
Monitoring Recovery ft. ft.
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Injection Well:
ft. ft.
Aquifer Recharge DGroundwatcr Rcmcdiation .
19.SAND/GRAV.EL PACK(If applicable) .
Aquifer Storage and Recovery IlSalinity Barrier FROM TO, MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. R. .
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING'LOG,(attach additional sheets if necessary)
-- -FROM TO DESCRIPTION(color,hardness.aall/rack type,grain else,etc.)
Geothermal,(Heating/CoolingReturn) (Other(explainunder#21Remarks) ® ft. 3 R. 561I
4.Date Well(s)Completed:a- 0 a 3 Well 1I)# 9 R• /5- ft• jiuur Pe C e
Sa.Well Locations I S ft. Zl2 s-Tt. , 13 kie t2i9 n J U)e
ft. d R. i 1
Facility/Owner Name: Facility.ID#(if applicable)-- ft. ft. I k-,!a-''''ur F-d r- '
4.-
e2q5C.1 !-J -f lvc rv1 s 11 a d 4;A 5a,iw ij c v1,►.0 ft. ft.
2 nn
Physical Address,City,and Zip �7,,,Z t/G ft. ft. JAI J. + C U 24
in
I l 21.REMARKS'
County Parcel Identification No.(PIN) ✓Y�.Y�Y-/.f�.�.�V{b1.,
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 22.Certification: jZ
N W ate,..;
6.Is(are)the wells) Eermanent or Temporary Signature of Certified Well Contracted^ Doc •
By signing this forms,I hereby cerlffy'that the tull(s)was(were)constructed'in accordance
7.is this a repair to an existing well: IjYes .or ONo with iSA NCAC 02C:0100 or ISA NCAC 02C'.0200 Well Construction Standards and that a
If Ibis is a repair,full out known well construction infirm cition and explain the nature of the copy of this record has.been provided to the well owner.
repair under#21 remarks section or on th-e back o/this form..
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: J �` SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: �/r2 JC.- (ft.) '24a. For.All Wells: Submit'this form within 30 days,of completion of well
Far multiple wells list all depths fifdperent(eranple-3@200'and 2@100) construction"to the following:
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10.Static water level below top of casing: fD (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing.use'+•' 1617 Mall Service-Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (In.) 24b.For lniection Wells: In addition to sending the form to the address in 24a
r. above,also submit one copy of this forth within 30 days of-completion of well
12.'Well"construction method: A,1 IZ J-a`i i 1 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) / LI Method of test: 5 I'917"j. 24c.For Water Supply&Inlection'Wells: In addition to sending the form to
j� J / the address(es) above, also submit one:;copy of this form within 30 days of
13b.Disinfection type: / ' T 17 Amount: )4 0 Z completion.of well construction to the county health department of the county
where constructed: 1
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-201'6

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GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environtriental Health,Water Qdality Unit
400 W.Market St.,Suite 300, Greensboro,NC 27401
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Record of Construction, Repair, or Abandonment of a Well
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Address of Well: 96-9 140 F Fine v1 )) 6 b5e0 tuviVe rt;C LATITUDE 3 .
Well Permit Number: ,2 3 - 6 -6.3w/i2 76 81S— LONGITUDE
Well Contractor Company: Aqua Drill, Inc. Completion Date:/62 35 -2 3
Total Well Depth: ft. Well Yield: ) 0 gpm Static Water Level: 6 0 ft.
Outer Casing Material: S pi 21 C Formation Log .
Casing Diameter:.6 Vc-/ in. Casing Depth: (4 3 ft. Depth Description
From: ft.To: 3 ft. 58 i
Inner Casing Material: From: 3 ft.To: /S-- ft. • ‘11.,ori.. 17a ct
Casing Diameter: in.. Casing Depth:, ft. From: lc ft.To:eacft. lake &TAW i 4 C.
From: ft.To: ft.
Grout From:. ft.To: ft.
Depth Material Method From: ft.To: ft.
From: 0 ft.To: 20 ft. Cermen4 /Lace From: ft.To: ft.
From: ft.To: ft. • From: ft. To: 'ft. •
From: ft.To:. ft.. From: ft.To: ft.
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Water Production Zones •
Depth: );20 ft. ft. ft. ft. ft ft. ft.
Yield: LO__.gpm gpm gpm gpm gpm gpm gpm
Method of Repair:
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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: /14.0.-s- /Z..; Certification t 2080-A Date: /2 -70 -2 3
Record of Pump Installation .
Pump Installation Company: Afonvt 44JU.. Az-A) C. , Completion Date:
Pump Depth: 3M ft. Static Water Level: r 0 , ft.
Pumpiliond: Cote/4V % MI 0 -2.51 Pump Size and Rating: hp gpm/5
%-A•3 Phnom...Lek
I hereby certify that this pump was installed and wellhead completed according to the Guilford.County Well
Rules in effect on thisdat a.nd7t a copy of this record has been provided to the well owner.
LAWell ContractorC,/ 74 Certification.41: - "1 Date: /04
Revised:January 1,2009
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