GW1--03261_Well Construction - GW1_20230511

WELL(C0N,9'MIJCTIn1V RECORD G 1 Print Form
-
1.Well Contractor Information: For Internal Use Only: - - -
Gary Thompson
Well Contractor Name 14.WATER ZONES
_ FRonr 4418-A TO DESCRR'TION
fe
NC Well Contractor Certification Number ft. tt
Aqua Drill, Inc. 15.OUTER CASING for multi-cased wells OUNiR ifa Geable FROM To IMCKNEss
D1Al�II.3- MATERIAL Company Name -� R. �� ft. C.2
,a3 w. i
2.Well ConstructionPermit#: 16.I NERCASINGORTUBING eotbermale lose ddoo
List all applicable arU construction permils(i.e.UIC,County,Stag yR,uxela)el MOM ft.
TO D1AMSrER
THICKNESS bfATER[AL
in.
3.Well Use(check well use);
Water Supply We➢; 17.SCREEN
grrcultural FROM TO Dr SLOTStZE TFRCKNESq ft
MATEPTAL
M icipal/PubIIc
Geothermal(Ifeating/Cooli S 1 D'
°g °PP Y) eside'.n Water Supply(single)
IndustriaUConlmcncial oResidential Water Supply(shared) ft 1°
Irri ation IS.GROUT
Non-Water Supply Well: FRODI To MATERLtL EMPLACEMENT a4ETnOD&�L1tOUNT
. Monitoring ft
Recovery /� c•v r -AA
Injection Well: ft rt
Aquifer Recharge DGroundwaterRemediation ft. %
Aquifer Storage and Recovery OSalinity Darrier 19.SAND/GRAVEL.PACK if licable
Aquifer Test FR0at TO MATERIAL EMPLACEMENThILTHOD[3StormwaterDrainage f. ft
Experimental Technology E3SUbsidence Control
Geothermal(Closed Loop) l Tracer ft ft
Geothermal 20.'7LIZINGLOG attach additional sheets ifneces
(Heating/Cooling Return) Other(explain under#21 Remarks) FRonr To
DESCRIPTION(color,hnrdnecs sotumc& e, in size,etc.
4.Date Well(s)Completed: J--L':.3 n rt c l u
Well ID# _0 % ft,
Sa.Well,Location: r ' �b�•!� �a{
lQ�/�eV B 7 ft.
—' �• rt
Facility/OwaerName i Ao-. F� „�..r
Fact7ityIDH(ifapplicab]e) tL ft. d
LZZ j /� f / t ° d• • ...
iiCe..�;p;1�Cr � �.V r. rt ft
Physical Atddtcss,City,and Zip 7
21.REIIIARI(g ft MA
County
Parcel Identification No.(PIN) First
5b.Latitude and longitude in degrees/miuutcs/seconds or decimal degrees: , ,+ JA '7h-
(if well field,one latilong is sufficient)
�� t�� Llet ti t 22.Certification:
rr�i' Z)d r4� Si3e1� w,
6.Is(are)the weII s Ad
() ermanent or OTempor•ay Si a of el
/ Dale
7.Is this a repair'to an existing wen: �Xes or o 83'signing thin jornr,!her
with 15.t NCAC 02C.0100�ISANC.AC 02C.0200 that the s)!Pe!!(OnstN constructed ardaccordance
a d�Q tcQ
Ijthls is a repalr,fill out known well cortstructlon it formation and explain rite naurre ojtlte coPY oj11tls record has been provided to the rve!!otivner.
repair under#21 remarks section or on the backoflhisj0rnc
m or additional wen
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
drillelied:d: NUMBER of wells construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: - M ZS SUBMITTAL INSTRUCTIONS
For inultlpleI_llr list all depths fd8erent(esample--1@200'and WOO 5 (ft) 24a. For—An Wens' Submit this form within 30 days of completion of well
10.Static water level below top of casing: L f b construction to the following:
f,,vater levells above casing;else ,+,, (ft) Division Of Water Resources,Information Processing Unit,
11.Borehole diameter: l0 1617 Man Service Center;Raleigh,NC 27699-1617
(in.)
24b.For Iniec�on Weps: In addition to sending the form to the address in 24a
12-Well construction method: above,also submit one copy of this form(i.e.auge�rotary;cable,directp„sb etc-)) construction to the following: within 30 days of completion of well
EWATERPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Method oftest: a P�v� '^^t24c ForWater Supaiv&h-iectionWells: In addition to sending the form to
ype 14'U '1 Dec the address(es) above, also submit one copy of this form within 30 days of
Amount: j �t- 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 Resour cs
Revised 2-22-2016
I

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W. Market St., Suite 300, Greensboro,NC 27401
or Ab
andonment ®f a wely
Address of Well: 0111.voti� Q G;'� Ear:�Ge ni 0 �.,
LAI'1�'U®E 3� _�1. o�
Well Permit Number: ��- ois �,,U„ p� ,��6rQ ���"�
LONGITUDE %ga
Well Contractor Company: , i� � Completion Date:_�`�i
Total Well Depth: �_ft. Well Yield: G gpm Static Water Level:
Outer Casing Material: P— formation Log
Casing Diameter: 6,ay in. Casing Depth: =757 ft. Depth p Description
From: E ft. To: �t'°`1
Inner Casing Material: From:�_ft. To: ft. ©ti < ,.,-
Casing Diameter: — y �y '
in. Casing Depth: ft. From: `P ft. To:`��' ft. _ G �.;F�
From:-m ft. To: -z- _ft.
Girout From: ft. To: ft.
Depth Material Method From: ft. To: ft.
From: ft. To: 2:�,� ft. cz�+.�,.�
From: ft.To: ft,
From: ft. To: ft. From: ft. To:
From: ft. To: ft.
ft. From ft. To: ft.
Depth: C ft. ft. Water Production Zones
ft.
f
Yield: fe___gpm gpm gpm im ft. ft.
gl gPrn gpm aPm
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:
Certification#: Date:
fccord of Pump nnstaNgate®�
Pump Installation Company: P>
Completion Date:
Pump Depth: Q ft. Static Water Level: Ft.
Pump Brand:s c?tt9 V �e Pump Size and Rating: j/ lip g m
I hereby certify that this pump was installed and wellhead completed according p
Rules in effect on th�iate a d that a copy of .'� record has been provided to the well owner. County Well
Well Contractor: r
Certification#:
Date:
Revised:January 1,2009