GW1-2022-09824_Well Construction - GW1_20221028

WJEILL CONSTRUCTION RECORD(GW-1) For Int®al Use only:
I.Well Contractor Information:
Cameron Bazin 14.'WATER'ZONES''.
FROM TO CRIMON
Well ComractorNamo ft. 0
4518-A fit. ft.
NCWcUContrs,.lorcertificationNumher 15.OLTERCASIPIG'formuld-cme -wells 3 ORLRQERfifa > I ti'
FROM TO DIAMETER THICKNESS
Aqua Drill,Inc. IL
Company Name -16.IMRCASING'O - ING -ebthermalslosed-]do
2.Well Construction Permitk Q FROM ft. TO DIAME In.
rER TtuuR Fss MATERIAI
List all applicable it-all corutrudion permits(ie.1l1G County,State,Parlance,eta.)
fG
f(,
3.Well Use(cheek well use): :..
17.SCREEN':
Water Supply Well: FAoaf TO DIAMETER SLO StWrE THICKNESS 1tATEtuAL
Agricultural D'MunioipaUPublic ft. it in.
Geothermal(Heatingicooling Supply)residential Water Supply(single)
IndustriaUCommercia! Residential Water Supply(Shared) 18.GROUT
_ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Irri ation O ft. ft hG�G
Non-Water Supply Well
Monitoring DRecovery ft. ft
Injection Well: ft fa
quiferRecharge DGroundtvaterRemediation 19.SAND/GRAVELPAGK Rcable
Salim Barrier FROM TO MATERIAL EMPLACEIttENTMETHOD
- Aquifer Storage and Recovery `� tY
- Aquifer Test o tormwater Drainange Ir. fit:
Experimental Technology OSubsidence Control IL ft.
Geothermal(Closed Loop) Tracer 2o.DRILLINGLOG attachadditionnlsheets"ifnecess
EROM TO DFsr-u flON(edar,hardnea,seVruck a r'in svr,eta
-"Geothermal(HeatmglCoolingRet=) n 0ther(W lair undcr#21Remarks) ft. 195 ft GOvIL
4.Date WeII(s)Completed: It.�� � . F;'�ID�
5a.Well Location:
fL
ffi fit. �'•� n.,0 L4_ � �Ya.E'
Facility/Owner Name Facility lDX(if applicable) .�
.$26 f�oSS�ct k rya.d dun�rsl�l� ft fL 02)
Physical Address,City,and Zip
�TIA���� 2LREMARK.4
County Parcel identification No.(PIN)
5b.Latitude and longitude in degreesfminuteslseconds or decimal degrees:
Cif well fietd;one Mona is sufficient) 22.Certification:
36. 11922 N .80,0234v?— W
SignamAfCi&dWeliContractar Date
6.Is(are)the wells)'.. ermancnt or DTemporary
By signing this form I hereby cerlo that thte wella)tuns("'ere)constructed in accordance
1.Is this a repair to an existing well: QYrx or No with 15A NCAC 02C.0100 ar ISANCAC 02C.0200 Yleil Constrrtction Standards and tlmt a
If this is a repah:fill out hmo"n irell Col..tetlon infonaut' and expfahr rate natrrre of the
cape of this record Iran been provided to the ttufl otvaer
repair under R21 sensor ks section or ors the hack of this L 23.Site diagram or additional well details:
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back this page to provide additional well site details or well
construction details.Youu may also attach additional pages if necessary.
construction,only 1(3W-1 is needed. Indicate TOTAL M1`0ER Of wells
drilled.- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24 5 (fit) 24a.For All Wells: Submit this form within 30 days of completion of well
Formultiple rvatis list all depths ifdifferew(example-3Q200'and 2Q1001 construction to the following.
1o.Static water level below top of easing: (fit) Division of Water Resources,Information Processing Unit;
lftvaterlevel is above casing.use"+ 1617 Mali Service Center,Raleigh,NC 276991617
IL Borehole diameter. 00 (in.] 24b.For Iniection Wells: In addition to sending the form to the address in 24a
0� ,� above,also submit one copy of this form within 30 days of completion of well
1
12.Well construction method: constructionto the following:
C"Le.auger,rotary,cable,dimtpush,cta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: / 1636 Mail Service Center,Raleigh,NC 27699-1636
Ma.Yield(gpm)' � Method of test rgh 24c.For Water Sunnly-&Injection Wells: In addition to sending the form to
6K the pddress(es) above, also submit one copy Of this forua within 30 days of
13b.Disinfection type: Amount ( 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 Revised2-22-2016
II

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W.Market St.,Suite 300, Greensboro,NC 27401
Kecord of Construction, Rspakro air abandonment of a Well
Address of Well: LATITUDES
Well Permit Number: ����� ��/i'°%r�� �3�� LONGITUDE V 2—
Well Contractor Company: /Alt/# L� ��� Completion Date:lal C 2-2-
Total Well Depth: 7_15 ft. Well Yield: gpm Static dater Level: 0 ft.
Outer CasingMaterial: '0�Z_ Fonnnattnonn Log
Casing Diameter: in. Casing Depth: B/ ft. Depth Description
lFrom:_,�P ft. To:/0:5 _I. V
Inner Casing Material: From:Z4S ft. To:247s'ft.
Casing Diameter: in. Casing Depth: ft. From: ft. To: ft.
From: ft.To: ft.
Grout From: ft. To: ft.
Depth Material Method From: ft. To: ft.
From: O ft. To: Z-7 ft. 74J.1 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: ZZ ' ft. ft. ft. ft. ft.
Yield: • ZZ 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 t t a copy of this record has been provided to the well owner.
Well Contractor: Certification#: ft Date:
Record of Pump Rusta5wdon
Pump Installation Company: r i t1 (1 Completion Date: 10 3- _N_�
Pump Depth: CC) ft. Static Water Level: ` +0 ft.
Pump Brand: 6:xn�A� a-9O Pump Size and Rating: I -S lip gpm
i
I hereby certify that this pump was installed and wellhead completed according to the Guilford Count Well
p g � Y
Mules in effect on this date ate a that a copy o this r cord has been provided to the well owner.
Well Contractor: "� Certification#: Oct 6, LP'f�_ Date:
Revised:January 9,2009