GW1-2022-08402_Well Construction - GW1_20220519

Annt;Fo im.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14::wATERZONEs
Well Contractor Name FROM TO DESCRIPTION
4418-A L110"' 4 1 ft,
(CI40 it. rt tve
NC Well Contractor Certification Number 15.OUTER'CASING for multi-cased:wellc 11 LINER rf a livable '
Aqua Drill, Inc. FROM To DIAMETER Tffil:[QdFSS MiA�TERIAL
Company Name ® ft Q!5 J25 In
��qt�►► .+.1 �^t ..I&INNER CASING:ORTUBING 6othdkrwil closed-loop),.
2'Well Construction Permit#: '91-f6"L0 U6.111-o4IXo'7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft, ft In,
3.Well Use(check well use): ft ft in.
Water Supply Well: 17:SCREEN .
_ FROM TO DIAMETER SLOTSI'LE THICKNESS MATERIAL.
Agricultural unicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft ia•
Industrial/Commercial DResidential Water Supply(shared)
•�18:GROUT... :; .. .. - ..
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
tt tt fi `, ,u y1
Monitoring DRecovery ft ft.
Injection Well: ft, ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if a 'livable
3-Aquifer Storage and Recovery IDSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage R• ft
Experimental Technology OSubsideace Control ft ft
Geothermal(Closed Loop) OTracer '20.DRILLING.LOG(dttachadditionaLshtets ifnecessa
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM To R DESCRIPTION(color,hardness,suivroek a mia size,etc.)
ft:
4.Date Welt(s)Completed: _5-3-,2t2 Well ID#
5a.Well Location: Q ft' 45 ft
P as", T;cY, Li 5 ft '70 It l!t -
FaciliWOwner Name Facility ID#(ifapplicable) ft, ft
daf(!LS'. sioyieSt'I��e, tUcx,3`J7 ft. it b l_t. •_�°. c +=r S.__.
Physical Address, i6 ty,and Zip R' ft MAY 1 9 202?
2l.REhfARKS
3
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certification:
ace 14' 14 " N I° ?.4 W /` ,✓ " Z„'3_
6.Is(are)the well(s)dpermanent or OTemporary SignaL re ofC ' ed Well'ContrActor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: r1Yes or ,' No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair wider#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-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: V0 00 24a. For Au Wells: Submit this form within 30 days of completion of well
For inuldple wells list all depths if dierent(example-3 200'acid 2@100) construction to the following:
10.Static water level below top of casing: y40 (fL) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing;use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter:� (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: 11@rLtd ills^ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
y e
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cente
r,Raleigh,NC 27699-1636
13a.Yield(gpm &A') Method of test: )- 1i4'1 24a 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: NTHW� IQ Amount: IG02 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

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W.Market St.,Suite 300, Greensboro,NC 27401.
Record of Construction, Repair, or Abandonment of a Well
Address of Well: 7CQ ff} Sln_Ih�grti��f�_PY_ltl_C LATITUDE 3 l�f
Well Permit Number: �1-t;.5���A}9It�9t9 �� LONGITUDE 560
Well Contractor Company: -Adota 0r:11 Inc. Completion Date: h.. 3-.7
Total Well Depth:_ 05 ft. Well Yield:gpm Static Water Level: 1-10 ft.
Outer Casing Material: �U(- Formation Log
Casing Diameter: (6,R5 in. Casing Depth: 46 ft. Depth Description
From: f: ft.To: 00 ,ft.
Inner Casing Material: From:-26 ft.To: tl0 ft., 6%
Casing Diameter: in. Casing Depth: ft. From. 46 ft. To: t16 ft.
From: 05 ft.To: �®_ ft. 'Le G -Urn"l8
Grout From: ft. To: ft.
Depth Material Method From: ft. To: ft.
From: 0 ft.To.: ft. n+ r 1- From: ft. To: ft.
From: ft.To: ft. From: ft.To: ft.
From: ft.To: ft. From: ft. To: ft.
Water Production Zones
Depth: Ll1r ft. Ll ft. ft. ft.. ft. ft. ft.
Yield: _I gpm y gpm gpm gpm gpin --gpm gpm
Method of Repair:
Method of Abandonment:
I hereby certify that this well was constructed,repaired,or abandoned according to the Guilford County We]I
Rules in effect on-this date and that a copy of this record has been provided to the well owner.
Well Contractor: ice" �` - Certification#: ' ' Date: �,
Record of Pump Installation
Pump Installation Company: _ (;t4��''' �� Completion Date:
Pump Depth: SOL) ft. Static Water Level: ft.
Pump Brand: �.c�-� SS��5�-� Pump Size and Rating: S- hp _gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on this date that a copy of this record has been provided to the well owner.
Well Contractor: Cz/ Certification#:vZ-lam, 12�- Date:
Revised:January 1,2009