GW1-2022-10819_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD(GW-1) For btemal Use WT
i.Welt Contractor Information:
Cameron Bazin 14.'WATERZONES•'.
FROM TO DESCRn'1TON -
Well ContractarName16 tt, it i
4518-A fL it
NC Well Contractor Certification Number 15:0UTER.CASHiG'formulfi-caseil•Wells ORI;1NERfff$ licatile .. '
Aqua Drill,Inc. FROM tt. To DIAMCrER Ta1CKNESs MATERIAL
[0in. P
CompanyName 16,IN RCASINGORTUBING eothermaldosedmoo ".
ti Constrvcdon Permit# FROM TOD1nMETER rtnclazFss MATEitInL
g
2 We
List a[I applicable we l construction permits(f e.WC,County,StatA Variance,eta)
• ft. D, iu.
3.Well Use(check well use):
Water Supply Well: ]FROM
SCREEN'.
IROM TO IDIAMETER I SLOT SIZE. THICKNESS MATERIAL
Agricultural �h1unicipaUPublic It. it tn.
Geothermal(Beating/Cooling.Supply) Residential Water Supply(single) rt in,
, IndustriallCommercial DResidential Water Supply(shared) I&GROUT '
Irri aYlOII FROM :TO MATERIAL t EMYWCEM1TENT METHOD&AMOUNT
Non-Water SuPPb Well, Q ft s .ft. 1TP/
Monitoring Recovery fL IL
Injection Well: it it
Aquifer Recharge DGroundwaterRemediation 29.SAND/GRAVEL PACK fif liable .
Aquifer Storage and Recovery oSalinkyllairier FROM zo MATERIAL E—CEnIENTMErHOD
Aquifer Test Stonnwater Drainage ft. ft,'
Experimental Technology tOSubsidence Control ft. it
Geothermal(Closed Loop) [3Tracer 20.DRILLI_G ILOG attachadditional sbeets Women..,
FROM TO DESCRIPTION.Lolor.hnidaas.so0/rack in' eta)
Geothermal(Beating/CoolingRetura). Other(explainundcr#2lRcmarlm) O ft .9 rt /� j•
4.Date Well(s)Completed:��Well ID# O ft. ft R
ft. R
5a.Well Location:
& ft
rt
Facility/OsvnerName FacilitylD9(ifapplicable) _*q_--"'�.`��
ft. %
7 4os U Mrs ft6re, 4^ L3r o��L r
Physical Addtess,,City:and Tip ft ft "
VIM
2L REMARKS.
County Famei Identification No.(FIN) L7, u
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(fwen field,onelatflong is sufficient) 22.Certification:
134- l5 M N - w � 1 2P
Signature of Certified Well Contractor Da
6.Is(are)the we0(s)t�l..Permanent or Temporary
/— By signing this form,I herehp cert fy thar the;ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well. �Yes or�o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards aml that a
If this Ira repair fill o:rt knoxst well construction•irrjennatio,�an"d'esplairr the nature of the SPY ofrhrs record/rasbeetr provided to the iuell rnvner
repair under 421 remarks section or on the back of this form
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Qosed 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 TOTALNUMBER of wells construction details. You may also attach addititmalpages ifnecessary.
I �
drilled SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: vGi J (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple we[is list all depths ifdifferem(esampie-3@200'and 2@100) construction to the following,
00 10.Static water level below top of casing: /O (ft) Division of Water Resources,Information Processing Unit,
Ifivaterlevel is above casing rise"+' 1617 Mail Service Cetrtcr,Raleigh,NC 27699-1617
11.Borehole diameter: _fn•) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this Ifornt within 30 days of completion of well
12.Well construction method: f d construction to the following
(i.e,auger,rotary,cable,d'nectpusb,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: C 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) [s Method of test 7 24c.For Water Sunnly-&Injection Wells: m addition to sending the form to
the address(es) above, also submit�,oue copy of this form within 30 days of
13b.Disinfection type: Amount --/`WaL completion of well construction to i e,county health department of the county
where constructed.
Form OW-1 Worth Carolina Department of Environmental Quality-Division of Water Rr-sources Revised 2-22 2016
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I
GUILFORD COUNTY DEPARTNBNT OF PUBLIC IiEALTI•I
Division of Environmental Health,.Fater Quality Unit
400 W.Market St.,Suite 300, Greensboro,NC 27401
Record ®f C®nstvucto®no Repali,, or Abandonment ®f a Well
Address of Well: �o8 L� �G lmn 4-1 LATITUDE 3 �o• �571
Well Permit Number: 22" O V- wr G— '0'n9 9` LONGITUDE 7 9yG�y
Well Contractor Company: ., 0611f Completion Date:1(12W 2- .
Total Well Depth: ZZ5r ft. Well Yield: gpm ' Static Wi.ter Level: 0 ft.
Outer CaSMg atertal: a✓G Formation Log.
Casing Diameter: in. • Casing Depth: loo ft. Depth Description
From:,Qft.To:9_ft.
Inneir Casing Material: From-.eft.To:Zg fL
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.• Oft.To From: ft.To•. ft.
From: ft.To: ft. From: ft.To: ft.
From.-___ft.To: ft. From: ft.To' ft.
i
• Water Production mimes .
Depth: 185 ft. ft. ft. ft. ft. ft. ft.
Yield: NP 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: � � LL 2: Ce;<tification#: �S 1 �T Date: 1•�
Pump Installation Company: : ,. Com' letion Date:
.
Pump Depth: 1 Q CJ ft. Static dater Level: k L ft.
Pump]Brand � � + m��~F'i05Dg Pump Size and Rating: 1 kx hp--�gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect onMth' datend that a c y of this record has been,provided to the well owner.
� !
Well Contractor: t Certification#c . Date:
Revised:January 1,2009.