GW1--03392_Well Construction - GW1_20230515

I
1.Well Contractor Information:
Gary Thompson 14,WATER ZONES, . . •
Well Contractor Name FROM TO DESCRIPTION
4418-A i is' it 1 z.-•-k m �r,+z..•t o-,-- 17 c,t r\
ft. ft.
NC Well Contractor Certification Number 15.'OUTER CASING(for multi-cased'rvells)OR LINER(if ap'livable)
Aqua Drill, Inc FROM TO DIAMETER THICKNESS MATERIAL
a ft., Nft. 4, ' in
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: :I:a-b 421°-w 1'i+1(k—05131 FROM TO DIAMETER 1 THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. M.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
f Agricultural OMunicipal/Public ft. It- in.
Geothermal(Heating/Cooling Supply) Im idential Water Supply(single) ft. ft. in.
Industrial/Comercial DResidential Water Supply.(shared)
.18.GROUT-. ..-
Irrigation FROM. TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C7 ft-
t �:� ft.
C.era ng y rb r --HLI�
Non-Water
Recovery ft. ft
Injection Well:
Aquifer Recharge Groundwater Remediation ft. ft.
19.SAND/GRAVEL'PACK'(if applicable)
Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Ls f Stormwater Drainage ft, it
Experimental Technology Subsidence Control ft. ft.
.'Geothermal(Closed Loop) O Tracer 20.DRILLING.LOG(attach additional sheets if necessary)' . ". . _ , .
Geothermal(Heating/CoolingHeturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
_ o ft 10 ft GI�y
4.Date Well(s)Completed: C`�.)'" Well ID# 1 b ft 5-6 f. Or/ 5 4 St 7
5a.Well Location: a et 5,., ft 6 CO:4Z�d.
•
l/A1r.r:I, Zke.t-i,7 5-5 ft to�- sr. 6 ,trri•��.
Facility/Owner Name Facility ID#(if applicable) ft. 'ft. Its: 4 ( in,
ft ft 1N t LJ U.•t V i_✓
Ll 9,1 is L.; 2 54•,,_ 94 rn(r(ti b;,(,;Alta. we:.
Physical Address,City,and Zip -P--t 3p 1 ft. ft - •
^,AY I 2073
Q/�� try s ` ,,Q 21:REMARKS• -
County Parcel Identification No.(PIN) Z
lrfiJ-Yth' •-�s, Y,3�,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: CH
:Ora
well field,one lat/long is sufficient) 22.Certification:
•
2 DI 1 14 t 1114 I' N 1 11
.Lf b'5'6.• i s<it t'' w t —-�-
tr� -n—••r '
6.Is(are)the well(s)Wermanent or '��Temporary Sigua re fled Well nthactor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or Et< with 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If thls Is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the r.el/owner.
repair under#21 remarks section or on the back of this form. .
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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 (eC (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200•and 2@100') construction to the following:
10.Static water level below top of casing: O . (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (( (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: t-P.•ry 'AV r construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ( Method of test: 1,,t:,+ne.- 24c.For Water Supply&Iniection Wells: In addition to sending the form to
/ o. the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: �`�� �n/!� Amount: I, �~ 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 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
7 scord x.,f C© -hstr ctRon, Repairo or Abandon .i end .•, W4 ti11
Address of Well: Li 13(4,_ L'.k1t. S•1-6 RQD to`c t 1 t. IN/L LATITUDE 3 Goa OS' i1
Well Permit Number: Da- b I/—wtv 14.a- b. S?,7 LONGITUDE `7 9-° Lib) b
Well Contractor Company: ; Completion Date:
Total Well Depth: I '5 ft. Well Yield: gpm Static Water Level: Liz ft.
Outer Casing Material: PUL Formation Log
Casing Diameter: („ 5 in. Casing Depth: S'5-- ft. Depth Description
From: za ft. To: }.a ft.
Inner easing Material: From: p ft. To: 5-,5 ft. p 5�, 1 Se;
Casing Diameter: in. Casing Depth: ft. From: 5-6 ft. To: 5 S ft. Gcya� l�
From: ft. To: t 4 S" ft. Gw i
Grout From: ft. To: ft.
Depth Material Method From: ft.To: ft.
From: D ft. To:2b ft. e.ewie.4 rna LA-ITi., From: ft. To: ft.
From: ft. To: ft. From: ft. To: ft.
From: ft. To: ft. From: ft. To: ft.
Water Prrodluctio,I Zones
Depth: yz.a ft. ft. ft. ft. ft. ft. ft.
Yield: 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: Atli Certification#: +-i c(-'k Date:
Rcc and of Pump nnstaatEt l;
Pump Installation Company: 1 ,6 LJ.o.. '- -�r 6 1 1--!MC.,, Completion Date: 5 4f1-
U � -S
• ii Pump Depth: 10 0 ft. Static Water Level: ° ft.
Pump Brand: l 13i t''S 1-- (1''‘. 5/ -Pi 3 525 Pump Size and Rating: l/ hp I a gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on the date an that a copy of tl ''re rd has been provided to the well owner.
Well Contractor: 7Y4. 2 � .// --7 .a Certification c 9
f ation#. - Date:
Revised:January 1,2009