GW1-2021-07545_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown A4.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2312 170 I'L 171 ft.
ft. ft.
NC Well Contractor Certification Number 13:OUTER CASING for mult44ased well§'OR LINER'if ko`Iicable
Raymond Brown well Company, Inc FROM TO DIAMETER TRICIM MATERIAL
0 ft. 61 ft. 6.1/4 1° sdr21 pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-lob
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) fL fL °'
3.Well Use(check well use): fL ft. in.
SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
HbEft Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fn ft, in.
Industrial/Commercial E31tesidential Water Supply(shared) 18'GROIIT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft* cement truck pour
Monitoring Recovery & ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK.(I a" likable
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology ®I Subsidence Control
Geothermal(Closed Loop) ®ITracer 20 DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc
0 ft. 15 ft. soil
4.Date Well 02/05/2021 ft.Completed: Well ID# 1s 54 ft. sandmck
5a.Well Location: se ft. 165 fL blue granite
Stacy Earl ft. ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
cc;CJE�Xlj
3618 Southeast School Rd ft. ft.
Physical Address,City,and Zip ft. ft.
P
Guilford 21 REMARKS
County Parcel Identification No.(PIN) 1m,3�tOD O(1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N w -(P,- C_ I 02/10/2021
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
pg� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or E)No with I5A NCAC 01C.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#21 remarks section or on the back of 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-I 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: 185 (R•) 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 casing: 70 (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: 1 (in.) 24b.For Iniection 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: 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) 40 Method of test: Sight 24c.For Water Supply&Iniection 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: Hth Amount: 15 oz completion of well construction Ito the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental.Health,Water Quality Unit
400 W. Market St., Suite NO, Greensboro,NC 27404
Record of Construction, Repair, or Abandonment of a Well
Address of Well: 36t� �6A94 at LATITUDE .3
Well Permit Number: LONGITUDE
Well Contractor Company: &e2rr� &n h(n Completion Date: S Z/
Total Well Depth: g�—ft. Well Yield: �4 gpm Static Water Level: .2a 'ft.
Outer Casing Material: ,�yc Formation Log
Casing Diameter: in. Casing Depth: T ft. Depth Description
From: ,!!�7 ft. To J ft.
Inner Casing Material: From: ft, To: ft.
Casing Diameter: in. Casing Depth: ft. From;/r ft. To3-j� ft.
From: ft. To: ft.
Grout From�_ft. ToAg,—ft.
Depth Material. Method From: ft.To: ft.
From: o_ft. To:Z o ft. ( Py,'r From: ft. To: ft.
From;: ft. To: ft. From: ft. To: ft.
From: ft. To: ft. From: &To: ft.
Water Production Zones
Depth: 17o ft. ft. ft. ft. ft.
Yield:. '/a 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: C—/t r J ,f i/r• /r' S Certification#:251t, Date; C '55 - a
Record of Pump Installation'
Pump Installation Company:�fA y�kp� Vy/(/ l , Completion Date:,
Pump Depth: ft. Static Water Level: 7a ft.
Pump Brand: cX,>9 Pump Size and Rating: YZ hp /0 gpm.
I,hereby certify that this pump was installed and wellhead completed 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: Certification 43 Date: .2 '7-0/
Revised:November$,2015
l