GW1-2022-07708_Well Construction - GW1_20220811

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only. Print Form
1.Well Contractor Information:
Chris King 14.WATER ZONES t
Well Contractor Name FROM TO DESCRIPTION
2080-A ft• ft.
--------------
NC Well Contractor Certification Number
.15 OUTERCASING formalti-casedwe ORLINER ifa ticable
THICKNESS MATE
Aqua Drill, Inc. FROM TO DIAMETER MATERIAL
Company Nano O ft. ft / in. Cj p! ram[J'G
/ ;16..I11'NER CASING OR TUBING" "eothermal dosed-loo F_ --
2.Well Construction Permit#.-�) J� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e UIC,County State,Variance etc.)— ft. ft in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
[ AgriculturalFROM TO DIAMETER- SLOTSIZE THTCKA'FSS MATERIAL
oMunieipal/Public If,
ft. is
Geothermal(Heating(Cooling Supply) esidential Water Supply(single)
fL in
Industrial/Commercial [)Residential Water Supply(shared)
I&'GROUT: ,
Ini ate FROM TO DfAI'ERIAi•, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Welk © ft' v ft- on 4—
ORecovery
In
ft, &jection Well:
Aquifer Recharge oGroundwater Remediation ft. ft.
_ Aquifer Storage and Recovery [)Saliniry.Beef 19.-SANDIGRAVEL PACK If licable
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft. ft.
Experimental Technology oSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING"LOG attach additional sheets if neces
Geothermal eating/Cooling Return) Other(ex lain under#21 Remarks) FROM TO DESCRIPTION color hardnessw s jtfrock type,grain sire,etc
4.Date Well(s)Completed: ' Well ID# `(� * 0 ft. ft `
C - mud
5a.Well Location: ft. C}} IMC
ft. -12 fL QZ"�
Facility/Owner Name Facility ID#(if applicable) ft. ft.
(��y� G— r ntc�Itn��,a1Z 1�1e�s n� �S�an�cttil Qv ft. ft ` (�
Physical Address,City;and Zip
ft, ft. I ( 1 2022
Lw; Fes_ 21.REMARKS
County Parcel Identification No.(PIN) If&VOia4io n Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certification:
. N W
6.Is(are)the well( lpermanent or Temporary Signature ofCemfied Wel Date
r
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes Oro with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 We11 Construction Standards and that a
1f 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 thisJomL
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: 1��� (ft)
For rnuldple wells list all depths if different(example-3Q200'and 2@100 24s. For All Wells: Submit this,form within 30 days of completion of well
construction to the following:
1Jwaterleve!is above casingg,,rise"+^
10.Static water level b top using: (ft.) Division of Water Resources,Information Processing Unit,
irs
f 11.Borehole diameter: (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
CD
jj 241b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:�f (Y�a ) above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following-
FOR WATER SUPPLY WELLS ONLY. Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3o Method of test: 1 C _ 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: X14- Amount: oz_ completion of well construction to 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

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GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health, Water Quality Unit
400 W. Market St.,Suite 300, Greensboro,NC 27p1
ecord Of Construction,, Repair,, Or AbandO6ment Of a Weil
Address 'of Well:
TITUDE 3
Well Permit Number:�Z,d C- -G�s�� �,� cl 7SY J%r`c
LONGITUDE
Well Contractor Company:Ao(} A (7;Zi 21 `
1 Completion Date:
Totalt Well Depth: ) j— ft Well Yield: 36 ��
°pm Static Water Level:- = ft
Outer Casing r Material: S /ZZI �
Casing Diameter: /�f in. Cas' a --�- Formation Log
1 Depth: �?� ft. Depth Description
Inner CasingFrom:�ft.To:j© ft.
Material: From j 0 ft, To. ft Casing Dirneter: in. Casin De the
g P $. From:Cl� ft. lo: �$.
From: ft. To: ft.
` Grout From: ft.TO:-ft.
Depth Material Method
From:-jr- fft.Tort ft. From: ft. To: ft.
From: ft.To: ft. From: ft. To: ft.
From:�ft. To: From: ft. To: ft.
TO.-ft. From: ft. To:
Water Production Zones
Depth: :eft. L;., ft. ft. ft.
Yield: _gpm �_gpm ft' ft• ft.
lam gpm gpm gpm gpm
Method of 12epair:
Method of Abandonment:
I hereby certify that this well was constructed,repaired,
Rules in effect on this date and that a copy of thisrec d has been provided tdo theow l owner. County Well
Well Contractor:
State Number: Gtyo Date:
®Record Of Pump Installation
Pump Installation Company:_ - 1��,i,cam �� �
Completion Date:
Pump Depth:--� _ft Static Water Level: e4D
Pump Brand:_rY-V fP-r'S � c�, h
Pump Size and Rating: p
I hereby certify that this pump was installed and wellhead completed according to,the Guilford County Well pen
Rules in effect on this date and that a copy of this record has been provided to the well owner.
Well Contractor: .���L�,�.
State Number: Zv X/,�_ Date:
10,
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