GW1--06784_Well Construction - GW1_20241114

WELL CONSTRUCTION RECORD(OW-1) For Internal Use Only:
1.Well Contractor information:
David Belcher 14.WATER ZONES I •
Well Contractor Name FROM TO DESCRIPTION
4594-A WO IL l/$a ft. dl eePh (re irfrt.^t'.)
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap Ilcable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 7 ft. 6, 5 in. DA.,'d ei)k
,,a� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ON-0 -kr3_�Irf(a' Of1C7,iW FROM TO DIAMETER THICKNESS MATERIAL
List all applicable tie!!construction permits(i.e.UIC.County.State.Variance.etc.) ft, ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Weli: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural nicipal/Public fL ft. in.
Geothermal(Hcating/Cooling Supply) gerResidential Water Supply(single) ft. ft. In.
industrial/Commercial 0Residential Water Supply(shared)
H.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
R
Non-Water Supply Well: . di ft. I�MN?4 9rur Th m.
Monitoring IJRccovcry ft. ft. �,tJi
Injection Well:
ft. f.Aquifer Recharge Groundwater Remediation SalinityBarrier 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Ell
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. It.
Geothermal(Closed Loop) ID Tracer 20.DRILLING LOG(attach additional sheets if-necessary).
Geothermal(Heating/Cooling Return) rOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soi0rock type.grain size.etc.)
/`� ft. .90 ft. --•
4.Date Well(s)Completed: I(U•(it•- 4 Well ID# c� ft. ,d ft.
5a.Well Location: ft. ft. a it_-ti�(,t�.i"
'Dream Weg '75 It. 52. ft. [ c/6. CZ!CJrV I
Facility/Owner Name ft. ft. ���Y Facility[D#(if -•-, 7
(L••ei66)gal 'D I(.ti i9114/e Or. Sf•�jteSdnit3� 'its' h?''e'�i�i" IL ft. z t. .T r ,--
t� I y (;
Physical Address.City.and Zi ft. ft N O t l I' �G Z4
�` ;co'j 21.REMARKS V -
County Parcel IdentiticationNo.(PIN) ltiF'3::+'• `' rf'`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
?G t' I 7.4" N cfOO I IL Co" w
9.j" %,g,(_____ ti•id-Nit
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby eertiii•that the ue//(.r)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 Hell 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 lion been provided to the well owner.
repair under#21 remarks section or on the hack o/'this fonn.
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:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: STay� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdierent(example-3@200•and 2 a l00•) construction to the following:
10.Static water level below top of casing: I (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: Co (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: Itc14.,^ ;(` construction to the followin :
(i.e.auger,rotary,cable,direct push,etc.) g
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1, Method of test:Cet}t".6 14•i ene. 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: PITH 7d�d`O Amount: 9ati•‘C7 completion of well construction toIthe county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

GUI LFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W.Market St.,Suite 300, Greensboro,NC 274011
011
Record of Construction, Repair, or Abandonment of a Well
Address of Well: ,72011 'Dorf;AO)c9P, V . Sick.,sf)4le.� ,ir<-,27 .5Y LATITUDE 3 Cry Xi . 1d
a j
Well Permit Number: 11-o5•f a! 419)- C418' LONGITUDE 50 I 3 i ,6
•
Well Contractor Company: kr jtr.,,l IrIlt Completion Date: i I•%•071/
Total Well Depth: 5(16 ft. Well Yield: Li :gpm Static Water Level: % ) ft.
Outer Casing Material: `Nils. Formation Log
Casing Diameter: 6..74 in. Casing Depth: 75 ft. Depth !Description
From: 0 ft. To: ::26 ft. eh"
Inner Casing Material: From: ,O ft.To: 7o ft.. P Secs J Casing Diameter: in. Casing Depth: ft. From: '7 �a ft.To:, �� ;ft. �l C"rr :aoe�
From: ft. To: Toki ft. lie &ramie
Grout From: ft. To: ' ft.
Depth Material Method From: ft. To: ft. ,
From: 0 ft.To: Qi ft. Ce( + ?pu;-45: h TrvcKFrom: ft. To: i ft.
From: ft. To: ft. - From: ft. To: I ft.
From: ft.To: ft. From: ft.To: ! ' ft.
Water Production Zones
Depth: LW ft, ft. ft,
ft, ft. ft. ft.
Yield: L_gpm gpm
gpm gpm gPm i 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 ow this date and that a copy of this record has been provided to the well owner.
Well Contractor: (Pm,.Q 1 ylllt:/. Certification#: 4594-4 Date: li•Co•,;711
•
- R . ord of Pump Installation L ,
Pump Installation Company: raani</ .'C Completion Date: ,// /2/z y
. Pump Depth: VQnj ft. Static Water Level: 416 I , ft. '
Pump Brand: G1ianWar Pump Size and Rating: / hp to gpm
I hereby certify that this pump was installed and wellhead completed according to 1the 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:
/47i e cfrthe Certification#:2C77-C Date: // Z
Revised:January 1,2009