GW1-2023-00778_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
2080-A It 5 it 0
fL ft.
NC Well Contractor CeriificetionNumbcr .15.OUTER CASING Mr mril&used..wells OR'LINER if a° Scable
Aqua Drill, Inc. FROM Ta DIAMETER THICKNESS MATERIAL
Company Name Q ft. 6 ft �,� I m. DR-2 (!r C
c
� ff "16.-INNER•'CASING OR-TUBING(eotliermal"crosed400 -
2.Well Construction Permit#:c�4vC - C�)j2I I�j�('( .�� FROM To DUMETER I THICKNESS MATERIAL
List all applicable well caustructlon permits(i.e.OIC,County,State,variance,etc.) It ft. In.
3.Well Use(check well use): ft. fL in.
Water Supply Well: .-17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS. MATERIAL
::Agricultural DMunicipal/Public fL M in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. & is
i ;IndustriallCommercial OResidential Water up.P,ly sparP -
_- r L''p r -T c :.IS.GROUT
IIr7 hOII tii, ,L '�`K,,Y ka-,,,� FROM TO .MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ` ""' " Q ft. Q ft.
Monitoring DRecove ` 7 3 ft. ft
Injection Well:
_- fL ft.Aquifer Recharge �Grouadwate;.Iteirpec)zattgn.=5:�r�L'rl I
{ tiyi �+ 19 SANDIGRKVELPACK if livable
_ Aquifer Storage and Recovery 0SA 9 Barr e�raj( :JD'G '
FROM TO I hIATERLu. EMPLACEMENT METHOD ~
Aquifer Test +QI- StormwaterDrainage ft. ft_
Experimental Technology OSubsidence Control ft. &
Geothermal(Closed loop) 0Tracer 20.DRILLING LOG Natta'chadditionalsheetsIfnecessa"
Geothem_ sal(Heating(Cooling Return) Other(e lain under#21 Remarks) FROM To DESCRIPTION(color,hardness soiVtaek a grain size,etc.
0 IL ft
4.Date Well(s)Completed:& -.?A Well lD# � fL 5-5" ft- `t • C&
5a.Well Location: 5 ft r ft. e ;• C
�A ?1 t,.��l— �-7 �Ves]f v'v ✓ tt ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
^td.3�- ft. ft. ,
Physical Address,p� s Jty,and Zip t� !�?3 I tt ft
(YJt`I YDC�C: .21.BENIARKS::.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Twell field,one lat/long is sufficient) 22.Certification:
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12-22-
6.Is(are)the well(s) harm anent or 13Temporary Sigbgrare of CertificdVell NatfaCtor Date
By signing this farm,I hereby certify that,the,well(s)'was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ON. with ISA NCAC 02C.0100 or ISA NCAC 026.0200 Well Construction Standards and that a
Ifthis is a repair,fill out'known well construction Information and erplain the nature of the copy of this record has beenprovided to the well owner.
repair under#11 remarks section or on the back'of thisform.
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 ifnecessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: fTS
For multiple (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
iple wells list all depths ifdifferent(example-3@200'and 2@l00� construction to the following:
��10.Static water level below top of casings (ft) Division of Water Resources'l Information Processing Unit,
If water level is above casing us/e`"+^ 1617 Mail Service Cenrter,Raleigh,NC 27699-1617
11.Borehole diameter: C17 24b.For Iniection Wells: 1n addition to sending the form to the address in 24a
�� ��/ above,also submit one copy of this foim within 30 days of completion of well
12.Well construction method: z. construction to the following.
(Le.auger,rotary,cable,direct push,etc.) j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test 24c 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: Amount: 9 AL 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 f Revised 2-22-2016

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GUMF®RD COUNTY DEPARnVMNT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unl t
400 W.Market St.,Suite 300, Greensboro,NC 27401
Record of Construction, Wallry or.Abandon ent of a Wag6
Address of Well:, f% ,j mac; p k lr�r f0 lAT7TUM 3 --
Well Permit Number:2Z W C z23 i 3'
! h)i 1!7 -066�,5 LONGITUDE
Well Contractor Company:X ) '� l�iz ) Completion Date: `t -, L—
Total Well Depth: 5� 'S� ft. Well Meld: S_
I gpm Static Water Level: ft.
Outer Casing Material:� rPi J, C Formation Log
f�
Casing Diameter. Z _in. Casing Depth: 6.3 ft. Depth Description
From: ft.To: � ft. [ G
g�ner Caauang Material: From: ft.To:S�S ft.. LZrGIL
Casing Diameter: in. Casing Depth: ft. From, y
�. ft.To:eft. ��(s
From: ft.To. j! ft.
Grout From ft.To: ft.
Depth Material Method From:. ft.To: ft.
Front: From• ft.To' ! ft.
From _ ft.To' ft. From: ft.To: i ft.
From: ft.To: & From: ft.To: ft
Water Production Zone
Depth: ft. ft. ft. ft. fr. j ft. ft.
Yield: �g pm gpm gpm '
-- .0pm 'pm 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 id effect on this date and that a copy of this record has been provided to the well owner.
Well Contra
ctor Certification Date:, — -
R12001rd WE Pump Enaft80atgon is .
Pump Installation Company: Completion Dater
Tamp Depth: .5 ft. Static Water Level: ft.
Pump Brand: I'
Pump Size and Rating:,_4 llp I i7 gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect oaa tI ' e a that a copy of thi record has been provided to the well owner.
Well Contractor. Certification
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Date:
Revised:January 1,2009