GW1--04470_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Gary Thompson 14,WATER ZONES
Well Contractor Name I FROM TO DESCRIPTION I
4418-A q)rt. kcA s a. rM
ft. ft.
NC Well Contractor Certification Number _
15.OUTER CASING(for multi-cased wells)OR LINER(if ap 0cable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name O ft. SS ft. 6:1,1 in. 1 S to R m PYZ
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 'ay- 05-\-.1 N k- Z - 0 0 60 S FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable dell construction permits a.e. U/C.County.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 4 MATERIAL.Agricultural DMuntcipaliPublic ft. ft. in.
Geothermal(Hcating/Cooling Supply) laRResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DRcsidcntial Water Supply(shared) — ,
18.GROUT
irrigation FROM TO :MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. a‘ ft. (..„,,,,fie
MonitoringRxovc �Otl(Z� L)l ittl tfJC
Q rY ft. ft.
Injection Well:
it. ft.Aquifer Recharge 0 Groundwater Remediation
Aquifer Storage and Recovery Salini Barrier FROM
SAND/GRAVEL PACK(if applicable)
FROM TO :MAFERLSi, I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage It. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock
Geothermal(Heating/Cooling Return) Other(explain under#2I Remarks)
soil/rockhpc grain sin,.etc.(
0
ft. 1 ft, ee a C 61
4.Date Well(s)Completed: 1-aa.-a,4 Well ID# 1 ff• $O ft.
$aAd.l Cock/ Cod
5a.Well Location: SO ft, 5 5 ft.
g'U,c Lrr c,sn i tC
Danlet tower.i Ijuste rsg ts+vcrssiors SS ft. 35 It. 81 ,;t 6-rant tt
Facility/Owner Name Facility ID#(if applicable) ft. ft.
I 96 Fc0,t o n Tca't\ Oo•k g.,Ag e NC a-1 310 ft. ft.
Physical Address
City,and Zip ft. ft.
1SU11tp(p , ir,6
21.REMARKS
County Parcel Identification No.(PIN) •)•r^yr,,; -t t 173
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/Iong is sufficient) 22.Certification:
le 10° a 4 N 11°SBt'-i5 I" W
Ikal^l -aa-a4
6.Is(are)the well(s)MPermanent or Temporary Si urc o crti dwell Cunt cmr Dam
By signing this firm,/hereby c•erufv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or at Nowith 15A NCAC 02C 0100 or 15A.NCAC 02C 0200 Well Construction.Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this.record has been provided to the well owner
repair under#2l 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: 3a5 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diff ferent(example-3(0200'and 242,100')
construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1 I.Borehole diameter: 6 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rt�tO,(y A)C
(i.e.auger,rotary,cable,direct push,etc.)
construction to the following:
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) i V Method of test: C.(Tk en 4 Tc me 24c. For Water Supply& infection 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-t 1 1t'lO°Ic Amount: 1 6 02 completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

GiTILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health, Water Quality Unit
400 W. Market St., Suite 300, Greensboro, NC 27401
Recivrd of Constructriong. Repaorlo or Aban for inrlerst of a Wail
Address of Well: EI9 6 Fa �"sg, � 13 i C�
0,,lc i� d_9 e _ -
C LATITUDE 3 1 6 -a i .
Well Permit Number: 4-o S- i.,lN N - UC1 0 8
Well Contractor Company: u a Liu_Lilac_ ""
A�
Completion Date: rl- a-3,y
Total Well Depth:`5 ft. Well Yield: ��
___1___ gpm Static Water Level: _ S_Q__ft.
Outer Cu°;,g Material: P\1C S Di;a.l
Casing Diameter: 6 'P i in. Casing Depth: S S ft. ®u°r�aitfl®�a Log]®eptla Description
inner Casing From:�_ft. To: -'7 ft. Rc ci C Ia.��
g Material: From:_a _ft. To: Sa ft,
Casing Diameter: ��.__u a in, CasingDepth: -�ndy i�ockv So.�
p _ft. From: S 0 ft. To:. ft. = t Li i{i
Grout
From: 5 S ft. To:39,S ft. _ ie &s n
From: ft. To;____ft.
`_Depth Material Method From: r
from: 0 ft. To: a 1 ft. CMatere ft. To: __ft.
Vow- w i 1�}tuck From: _ft.
From: ft. To: ft, -�-- ft. To:
ft. To: ft From: ft. To:___ft.
From: ft. To:___Mft.
Depth: (aCL ft. Water Production Zones
ft. Pt.
Yield: I O gpm ft. �....__ ft. ft. ft.
gpm gpm ..___gpm gPm gpm
----gAm
Method of Repair:
Method of Abandonment.
I hereby certify that this well was constructed, repaired,or abandoned according to the Guilford County Well
'ules in effect on this date and that a copy of this record has been provided to the well owner.
Well Contractor:
__&44:g.az
t:
-. . Certification#: i.2-.2.Lt Dom:
cord off Pump nfllSt c kalid0l
Pump installation Company: C47 /// ---;?
_ Completion Date: �7 2 d y
Pump Depth: 3oC�_ft. Static Water Level: l
pump Brand: �ir..,el�v _..�ft.
1 Pump Size and Rating:.__) hp
I hereby certify that this pump was installed and wellhead completed according to the Guilford Cou ` gpm
Rules in effect on this e an that a cop of th' record has been provided to the well owner. my Well
Well Contractor: T `._
Certification # 116 4 1 Date..
0 22
Revised:January 9,2009