GW1--04433_Well Construction - GW1_20230710

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
David Belcher 14.WATER ZONES- '
Well Contractor Name FROM TO DESCRIPTION
4594-A 110 ft 1'7?) it 15 e9m CFcrtt_ url?)
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL�
0 ft. 75 ft. /• !15 in. C/(UQ �I1 I VC
Company Name l9•d _]V 770t
n , 9 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: Qrr(-d Ce- IA..)fr3 49- ()roof?f) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. 1n.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural I°Mtmicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) i (Residential Water Supply(single) R. ft. in.
Industrial/Commercial °Residential Water Supply(shared) °IS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&-AMOUNT
Non-Water Supply Well: 0 ft. a7 n (L4PtK2r'•�' � (ith 8 Try
Monitoring °Recovery ft. a `�'�„� (
Injection Well:
Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stormwater Drainage ft. a
Experimental Technology °Subsidence Control ft. -ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional`sheets if necessary) • -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) D nQ C.
•
oCft. r
4.Date Well(s)Completed: (o•a6.9A Well ID# c90 ft. 70 a M !;
5a.Well Location: - 7O ft J!- ft Site &(j,I(Mt
Chnd g111 75 " a rut r5lue (te nni-1e
Facility/Owner Name Facility ID#(if applicable) ft. ft
(g►l4 1-rscrlps- ? •)I Sultan I AJG aZag3 ft ft - s _� ??
Physical Address,City,and Zip ft. ft
t�lllltP9fl� 21.RE11fARKS 'It IIL,.1 fl /1i/'i..
County Parcel Identification No.(PIN) J J
iI1fccr,-%11771 `ir.^.r,r:'e4C';.j tyre.e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ^,•=•-,'3,^.'"
(if well field,one lat/long is sufficient) 22.Certification:
35° 58, 65.g" N v9° 3(,' 54 6" w
( b 4>t,Q (j.Q,�,t---- •are•a
6.Is(are)the well(s) Permanent or (°Temporary Signature of Certified Well Contractor Dan
By signing this form,,I hereby certlfit that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: iii Yes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this ferns
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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a©5 (t) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200•and 2(gI00') construction to the following:
10.Static water level below top of casing: 1.1 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: ep (in.) 246.For Injection 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: egerl'aCt Q Arf 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) 15 Method of test: G1 rk t 4 Trim° 24e-For Water Supply&-Injection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 14 tH '7O /O Amount: . I61,C1Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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GIRD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W.Market St.,Suite 300, Greensboro,NC 27401
%Gard ConeSt action, Repair, ©ll Abandon'gent of a Weig
Address of Well:.61►0 Fenner e1 , iron/ JJC O11aQ'3 LATITUDE 3 5 5 ' 55 . R
Well Permit Number: gg-Ord-W 1)1-1`V,-c 0007c LONGITUDE 79 SG 5y , Co
Well Contractor Company: Affin. (OVA Xnc Completion Date: <o•;G �3
Total Well Depth: 2o5 ft. Well Yield: 15 gpm Static Water Level: L-In ft.
,LLuter Casing Material: BUG Formation Log
Casing Diameter: G.R6 in. Casing Depth: '75 ft. Depth Description
From: O ft. To: go ft. CI
I u,er Casing Material: From: go ft.To: 7O ft. M
Casing Diameter: in. Casing Depth: ft. From: 70 ft.To: 75 ft. i,1tie C(sao1.4e
From: 75 ft. To: deA ft. lilt to Crmn I4e
Grout From: ft.To: ft.
Depth Material Method From: ft.To: ft. •
From: (°) fr•To: Q7 ft. &i n+ w,4n1 ttc1 From: _ ft.To: ft.
From: _ft.To: ft. From: ft.To: ft.
From: ft.To: ft. From: ft.To: ft.
Water Production Zones
Depth: 1170 ft.. ft. ft. ft. ft. ft. ft.
Yield: 15. 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: nt %_61, , Certification#: g159u-A Date: Co • aro•
t>;_.^'_—__ "�;=a•a.9bk%�.�Hiat'.. .; 9-,<•-e F....+L-v.x. ;=^.4• .... sl,r-s .. �.c:iahIYrac.•:i's:ftomalowal4ofs.M'ImA'Itr!4:deo
rawe
Record of pump Enstail9ait©
Pump Installation Company: � - '� �\ - . Completion Date: "`-0!
Pump Depth: e 0 0 ft. Static Water Level: 40 , ft.
0-1
Pump Brand:-•�``�q Le,„ . . 1 a�-t - 10 Pump Size and Rating: 3,LE hp )() gpm
4"\�V�PCIJ`C
I hereby certify that this p mp was installed and wellhead completed according to the;Guilford County Well
Rules in effect on th' to and at a copy of th', eco has been provided to the well owner.
2
Well Contractor: Certification#: =laC.;of Date: —1
-Revised:January 1,2009