GW1-2022-10817_Well Construction - GW1_20221209

Pt'1nt:Fgrm'-.:.
WELL CONSTRUCTION RECORDfGW-11 For Intema)use only
1.Well Contractor Information:
Cameron$azin la.MATERZONES•-
FROM TO DESCRrmoN
wellcomractorNome I r ft. %
4518-A c a ll fL i
NC Well Conhaclorr-efiS er eationNamb is.OUTER-CASING'formult!-cated•VveDs ORLIM' If liabble •=eacxi�ss -
Aqua Drill,Inc. FRont To Drant�rER i x
0 [t n w fL In.
CompanyName 03 r 1,.,� �/J�J�(�j •16.INNER'CASIN(/GORTUBING thermal dosed-]oo ,
w 'JYjIll' 4w�+ FROM TO DIAMEPER THIC[OQ�SS MA1ERrAt
2,Well Construction permit#: It. ft In.
List all applicable mell construrBan permits(Le.t11G County,State,111-Hance,etc)
fL R in.
3.Well Use(check well use):
17.SCREEN•:'
Water Supply Well: PROM TO DrAmtErrSt SLOTSIM TyrClSIu:SS TFArERIAL
Agricultural OMunicipaltPublic fL
_-Geothermal(HeatingtCooling Supply) J r14 Pesidential Water Supply(single) ft tt to.
IndustriallCommercial `-Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPL,tCRMENTMETROD&AMOONT
�Irrlzation R, IL
Pion-Water Supply Well:
Monitoring Recovery D• IL
Injection Well: tr ti
Aquiferltecbarge OGroundwaterRemediation I9.SANDIGRAVELPACK ifa ➢cable .
Aquifer Storage and Recovery OSalinityBarder FROM TO MATERrALi EMPLACEMENTMETHOD
��StomrwaterDraina fL fa
Aquifer Test r
fL
Experimental Technology OSnbsidence Control R'
Geothermal(Closed Loop) ©fTracer 2o:DRILLING LUG attach addmonal sbeets'if necess
FROM To DESCRIPt•lON color bnrdnea,miUroc& e, rain saq elm)
Geothermal(Heating(Co2 {{R/eturn) i Othcr(cxplaiaundcr#21 Rentaslts) D• ® ft. I.
4.Date Well(s)Completed: f( Well 1D# ft. IL
R It. 6
Sa.Well Location. ft.
6�
1
Facility/O�vnerName Facility lDO fapPuw
ftble) ft• R iyz a
I ' ft.
l -
' fL ft DE
Physical Address,City.and Zip
2L REMARAS (i.,
A'`IK„I fqu, I 1fl�ivi iTiniL nlm F i.^.,^�x+y`'
County Pa=lIdc - cationNo-(?IN) rv�
5b.Latitude and longitude in degrees/minutes/seconds or decimal.degrees:
(f well field,one Mong is sufficient) Q/_ 72.Certification: 1
3-4 1 Z9 N /7 77�1 W L�� e
Signature afCmt&ed Well Contractor Iate
6.Is(are)the♦vell(s) Pertnanent or �ITemporary
rrBy signing this form,Z Icereby certfy tha{the tveR(s}tv¢c(were)mnstruated in aaeordance
Ms this a repair to an existing we➢: Oyes o No uith ISA NCAC 02C AI00 ar ISANCAC 02C-O200 WeII Constractian Standards and d'at a
vlded to thb well mvaer.
Ifthts is a repair,flit aat[moan uWl coustraction infatmati and explain the nature ofthe copy ofthis record has been pm
repair mtder 021 rmnarks section or an the back of thlsfarm. 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 OW-1 is needed-Indicate TOTALNUMBER ofwelLs
construction details.You may also attach additional pages ifnecessaty
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z 2 (ft) 24a.For All Wells. Submit this jform within 30 days of completion of well
For multiple wens list all depths i,fd,ffere,t(example-3@20000•and 2@100� construction to the fo➢owing.
10.Static water level below top of rasing: 7 . (t) Division of Water Resources,Information Processing Unit
Raleigh,NC 27699 Service Ceu
lf,vater[curl is above casloz usa'y' 1617 Mai! ter, 1617
11.Borehole diameter. Qn.) 24b.For infection Wells: In addition to sending the form to the address in 24a
above also submit one copy of this form within 30 clays of completion of yell
12.Well construction imethodt' ly construction to the following.
(Le•auger,rotary,cable,direct push,ctc.)
Division of'WaterResomrces,UndergroundNection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Canter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of tesUAY- 24a for Wafer Suonly-&Ini ID addition to sending the fntm to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount: lit • completion of well construction u the county health department of the county
where constructed.
Form GW-I North Carolina Department ofEwdronmcntal Quality-Division of WaterResomcm Revised 2-22 20M
r

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 ®f a Well
Address of Well: 712y 4rWI6 GI,ak !h LATITIup 3 /S7yd
WeII Permit Number: L,ONGITUbE _;9& '-0
Well Contractor Company: AGL&. nab/ Completion Date: 6
Total Well Depth: 27 S ft. Well Yield:3o gpm Static Water Level: VO ft.
Outer Casing Material: Formation Log
Casing Diameter:�_in. Casing Depth: ZO ft. Depth Description
From: O ft.To: N' ft.
Inner Casing Material: From:-&—ft.T02"' ft. 4'
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: ft. To: ft. From: ft.To: ft.
From: ft.To: ft. From: ft.To: ft.
From: ft.To: ft. From: ft.To: ! ft.
Water Production Zones
Depth: ft. ft. ft. ft. ft. ft. ft.
Yield: '?V_gpm gpm gpm gpm gpm gpm gpm
Method of Repair:
!I'Method of Abandonment:
i
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. Certification#: ys Date:
Record ®f Pump Installatloln �.
Pump Installation Company: J ,� Completion Date: h
Pump Depth: I ©D ft. Static Water Level: 4p, ' ft.
Pump Brand: - to L.-9i Se ra(yN11)—f 1p;_[j!Sjqump Size and RatinI i hp Ti7 gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on "s ate- d that a copy f th' record has been provided to the well owner. l
Well Contractor: Certification 4- gal` "Date:
Revised:January 1,2009