GW1--03394_Well Construction - GW1_20230515

Print WELL CONSTRUCTION CONSTRUCTION RECORD(GW-1) For Internal Use Only- -- --
1.Well'Contractor Information:
Gary Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A tf 4'� ft. Ll I-vt aCJ.'r -yd C,prf
ft. ft.
NC Well Contractor Certification Number
IS.OUTER CASING(for"multi-cased;wells OR LINER if.a licable
Aqua Drill, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. S in. 5 D P'-L I
-y 16;INNER CASTING OR TUBING eothermal closed Too ._
2.Well Construction Permit#:_.1.� ll.) �� (�br FROM TO DLOIETER THICKNESS I1fpTERL4I
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc..) ft. ft. in.
3.Well Use(checkwell use): ft It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIA4
Agricultural DMunicipal/Public ft. ft. in.
Geothermai(Heating/Cooling Supply) ' esidential Water Supply(single) g• ft in.
IndustriallCommercial DResidentiaI Water Supply(shared)
18.�GROUT
hl anon FROM TO RTATERtAL EMPLACEMENT METHOD&AMOUNT
Nou-Water Supply Well: 6 ft. .-Z-0 ft.
Monitoring [)Recovery
Recove of✓ ;�C r t t j(
ft. fL
Injection Well:
- Aquifer Recharge �GroundwaterRemediation R' R
Aquifer Storage and Recovery �,Sajthti Barrier 19.SAND/GRAVEL PACK(if applicable)
t'=�P y FROM TO MATERIAL EMPLACEMENT METHOD
'Aquifer Test 0Stormwater Drainage ft. ft
'_ Experimeutal Technology OSubsidence Control ft. fL
Geothermal(Closed Loop) IDTracer 20.DRILLING LOG attach additional sheets ifnecessa'
Geothermal(Heatin&Coolin Return) Other explain under#21 Remarks) FRORI TO DESCRIPTION(color.hardness,mUtraek a emin size,eta
ft.
4.Date Well(s)Completed: t Well H)# 1 D h• u ft,
5a.Well Location:
t � � ft. ft.
vF
�(a't�`t�.te,r �•.�4�` �, trn e,s Z� : w
Facility/Owner Name Facility ID#(if applicable) ft. ft '" E4
4 �1 �.U�ier ��CQCewiY�C1t l.itL1Br_ rizunt ft. ft. l v LJ
Physical Address,City,and Zip 1/WG ft. ft.
1'7 i jrfof,y,!r s D'l iDf^G tiiXvTr 1.+@`.
c'� t ;-r& 2LREMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
76- 3 '-p 6 IL,' 1 . i'aL�rt N ! � I , 1/2-C t VS 0
6.Is(are)the well(s)OP, rimment or OTemporary Srgna a Of'Certified Wall Contractor Date
� By signing this jann,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or 121VO with 15A NCAC 02C.0100 or 15A NCAC 02C.02oo Well Construction Standards and that a
If this is a repair,fill out Mown well construction information and explain the native of the copy of this record has been provided to the well owner.
repair under 0y1 remarks section or on lite 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
f � SUBDiUITAL INSTRUCTIONS
9.Total well depth below land surface: Ly (ft) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100D
construction to the following:
Ijwater level is above casing,use
f Static water level below top of casing: (ft.} Division of Water Resources,Information Processing Unit,
"+ff•' 1617 MPaiI Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: `P 66 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r b Ycat`4d kj;r above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) 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
13a.Yield(gpm) 3 t7 Method of test: i-oL4 :'+�G 24c.For Water Supply&Injection Wells: In addition to sending the form to
0 l �� Ley o the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: t 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

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W.Market St., Suite 300, Greensboro,NC 27401
ReCard of Construction, Repair, or A�an�on ent of a Well
Address of Well: — ,k,,r-ekeLAjotrD �.:•`��1� �.,���.�,� -F- j
LATs�uoE 3
Well Permit Number: %^a� i��c�r,� t �� t� wQ``-'j-I,,"I..
LONGITUDE
Well Contractor Company: Completion Date:. . 7 - ,l
Total.Well Depth: % ft. Well Yield: gpm . Static Water bevel: ft,
Outer Casing Material: �U L Formation Log
Casing Diameter.f�, _in. Casing Depth: "13- ft. Depth P Description
From: 0 ft.To:
lE InnerCg Material: r t, ft.To:
in.
Casing Diameter:
Casing Depth: ft. From:-2o ft.
From: _ft. To: �5 ft.
Grout From: ft. To: ft.
Depth Material Method From: ft. To: ft.
From:t� ft..To: a.6 ft. ew,er,�` v�•- From: ft. To: ft.
From: ft. To: ft. From: ft.To: ft.
From: ft. To: ft. From: ft. To: ft.
Water Production Zones
Depth: 1 l9-D ft. ft. ft.
-s ba ft. ft. ft.
Yield: ym gpm gpm Crft.
ETrn 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: Certification#: '-V IeL<�-A Date: j- - �
o
Retard of Pump ga1
Pump Installation Company: A c
�—' - Completion Date: Li
Pump Depth: I ft. Static dater bevel: `'�" u ft.
Pump Brand. , S'E-- Pump Size and Rating: ' h �D a m
p �p
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well Rules in effect on this to and/hat a copy of th's record has been provided to the well owner.
"2 Well Contractor: !
Certification#:r "� _ Date:
Revised:January 1,2009