GW1-2023-00777_Well Construction - GW1_20230112

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Pnrit Form,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER:LONES. . 666p
Well ConhacTorName�i FROM1i TO DESCRIPTION _
/ l.�'�/-� ft. eft `r.,� �_/. �• r ,�"
ft. ft i I J
NC Well Contractor Certification Number i
15.OUTER CASING for multi,cased'wells`OR LINER' fa licable)_
Aqua Drill, Inc. FROM TO DI"WTER ILU E brA L
" ft. ft
CompavyName ) Zj U l
.16,INNER'�GA I1�GORTUBING` otherma closed400 °.
2.Well Construction Permit#:. �-T E S` (y FROM - TO DIAMETER THICKNESS MATERIAL
List all applicable well construction.permits(i.e.UIG Count);State,Variance,etc..) ft. ft
3.Well Use-(check well use): ft ft in.
Water Supply Well: 47:SCREEN
:)Agricultural (. Mt1lliCi allPubltC FROM TO DTAMETER'• SLOT SIZE THICKNESS vATERTAL
__ p ft. ft in.
Geothermal(Heating(CooHng Supply) JUResidential Water Supply(single)
ft. ft, ra'
Industrial/Commercial E3Res1d n1lp�,llaterSnlspl (Share"`d),
J •, ti:_GROUT
hIl atiOn FROM TO MATERIAL E11iPLACEMEN'T METHOD At AMOUNT
Non-Water.Supply Weil: ft.
Monitoring ; Recovery ,J A N t 2 2023 ��
Injection Well: ft ft
Aquifer Recharge �Grou�dw¢;ecRein`ediafiop��„"-
Aquifer Storage and Recovery Sa' ' Barrier 19:SAND/GRAVEL PACK if a licable
� ERODi TO \L►TER[AL EaiPLACEMERTM1TETHOD
Aquifer Test 11'Stormwater Drainage 1I ft
Experimental Technology EISubsideace Control ft. fL"
RGeothermal(Closed Loop) QTracer 20-DRILLTNG;LOC aftach additionalsheets if necessan-• _; ..
Geothermal(Heating(Cooling Return) i` Other(ex lain under#21 Remarks) FROM TO D PTION(color,hartlness soi0rock a rain s ze etc
� �✓ ,
4.Date Well(s)Completed: Well ID#
5a.Well Location: fL ` ft K
/ v
ftC.'
Facility/Owner Name Facility ID#(if applicable) ft.
Phy Teal Address,City, Zip /V C _ •+z I
f1L P-r7 lr-! tl 21.ItEMARICS;,,
Rut' Parcel lde itification No.(PIN) .rd1L G/J f'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one lat/Iong is sufficient) 22 brtiticatio hf
.
6.Is(are)the well(s) Perulanent or Temporary i fCerti6ed We11 n to
By signing this form,I here fy that the wel!(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or No with ISANCAC'02C:0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fr11 out!Drown well construction information 40,derplain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 1
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 constmction details. You may also attach additional pages if necessary:
drilled:
p 17-i/ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths ifdifferent 06;nple-3@200'mtd 2@100) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing.
Ifwater level is above casing,use"+ `�---(ft) Division of Water Resourms,tInformation Processing Unit,
1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ��� above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,ditectpusk etc.) r 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
t
13a.Yield(gpm) Method of test: rl 24c.For Water Supply&IniectionIWells: In addition to sending the form to
the address(es) above, also submit one co of this form within 30 days of
13b.Disinfection e: Gf t 1 copy ys
type; Amount completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016

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GUELFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality bilit
400 W.Market St.,Suite 300, Greensboro,NC 27401
R'BC'Drd Of ConSto'UCtl0n,
Address of Well:
Well Permit Number: �G(- ��/ �. � _�� �/
' / C
Well Contractor Company: � � ' tLONSITME
Completion Date. �'��j 2
Total Well Depth: ft. Well Yield:
gpM Static Water Level•
Outer Casing 1Viaterial• P �
Casing Diameter.�in. .Casing Depth: .� - ft.� � lEor�aa�s®tn]Log
]7epth pia r�
Baer C From: ft.To: De
Material: fit.To.
Casing Diameter: in. C g - From:
asin Depth• ft. From:, eft.Toff-
FromJft.To:2 ,5 ft. �,��
Grout Frotn: ft.To: " ft.
Depth Material
�_J Me hod
FroYn:�.fL To:_'t. �L From: ft To: i ft.
From: ft.To- ft, —`��T From: ft.To: ft.
From:
Froiri: ft.' o- & fL To: I ft.
From: ft. To. ft,
.�
,
Depth: Water Production Zones
p - ,[ fL it fC.
Yield. ft.
ft. it
gPm : ft. ft.
gpm gpm gpm gpm gpm gpm
Method of Repair. ;
Method of Abandonment:
T hereby certify that this well was constructed,repaired,or abandoned according to the Guilford Count
Rules id effect on thisVet a copy of this record has been provided to thy; nrell owner. ydell
Well Contractor: L C
Certification Date:
R@Corr of Pmw, 8nsta-088RQon a
Pump Installation Company: 1, D '. � , 11_c�
Completion Date: I
Pump Depth: ft- Static Water L,evcl: ft.
Pump Brand:
Pump Size and Rating: ' ' `{ hp apm
I hereby certify that this pump was installed and wellhead
Mules in effect completed according to the;Guilford Coup
on thi ate a that a copy of this record has been provided to the Snell owner. ty Well
Well Contractor. t' `
Certification s-a- _ Date: �/ , 7
ROVI58d:January 1,2009 j
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