GW1--04436_Well Construction - GW1_20230710

WELL tCONSTRUCTION1 C��➢3(tGW_1) For Internal U only: Prim:Form.
4.xa�--�w.r.. —
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. •1.Well Contractor Information: • -
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David L. Hardy, Jr. 14.WATER ZONES• :. :•—•'1 -'I . '
Weil ContractorNeme
FROM TO DFSCR1P11OAt
29®s,A x:fie 1/5 1-16,, to a'G.:/-f
NC Well Contractor Certification Number
IS..OUTER CASING(for multkased wells)OR'LIN=(Nan lieabtc) •
Aqua Drill, Inc. - , FROM To DIAMETER LITIta2SSv pJ ..TIAL� _
•
. Company Name "'Si' n ft 1 ft. I �"� la , /
�j '` 16.INNER CASINe'OR TUBING( thermal osedaoop) i) Lr
2.Well Construction Permit#: 4/'"t l Z"luter�--61 C/7) FROM TO D THICKNESS MATERIAL
lift all applicable well construction permits(La VIC,Couny,Sate,Varianec,eta) / ft. - f6 in.
3.Well Use(check welt use): ,
Water Snppty Welk 17.SCREEN
Agricultural MunicipaI/Public FROM TO DIAMETER SLOT SIZE THICKNESS MATFR/AI. . .
0 f. ft
Geothermal(Heating/Cooling Supply) aResidential Water Supply(single)
Industrial/Commercial - ft n'
Residential Water Supply(shared) 1&GROUT
Irrigation FROM - TO M&TERIAL i ERLEIACCMENEn aODesA:Dery Non-Water Supply Well: ,�q /�7/7 Lr�iy!
Monitoring ORecovery `' ft. " ~� . ft.
G td �� � ��
Injection Well: . .
Aquifer Recharge DGmtmdwaterRemediation
uiferStorage and Recgvery �Salini[yBaaier Is.SAND/CRAWL PACK6M FROM HO MATERIAL - EMPLACEMENT METHOD
Aquifer Test DStonnxaterDiainage ft. ft
Experimental Technology °. Subsidence Control ft. • ft. •
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Geothermal(Closed Loop) DTracer 20.DRli.LiNG LOG(attneb edtlffionil sheets if
Geothermal(HeatinglCooling Return) PROM - To D _
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Other(explainunder#Z1Remarks) N(twmr, matmrlcrne.min: eta.) i
4.Date We$(s)Completed:, // /jvufl)# /•7ft / ft' �) r Gle . -
So.Well Location: / 07 v
Fecni /OwnerNeme F� ( / ra c- fir..-
�� _ Me(ifepptie abie 'ri'' •.J 1- . e a.
A.34-/A4!d'��%ci1G'k/ ✓4') ft' .. tl
. p>ry-� �tqA. Net 2 .73 ft. ft. I jlil 20?3
lriA�•� j 7. 2f:REMAR1(S r 3lir-3 - •
County Paralidentificatfon No.(PIN) i er1( --iS:"i` z}: '—•-1
rar,vc
5b56.,Lotifude and I lode in d ! '.
.L field,ear belly t minutes/seconds or decimal degrees:. •
//gong' Meient) `� �j/ ,rq -•s d.•
_
1 // /q� N i /r�`�f?,�V noon: �,g .,
W 7 ` .s
6.Is(are)the well(s)?,^•'Permanent or t-. � J S
�d emporetry Si o Cerofied Well Contractor d ate -
7.1§tills a repair to>m existing welt: Yes or By signing this form,I hereby c •••that the we/l(s)was(lave)contracted to accordance
O with 15ANCAC 02C.0100 or!Sit NC4C 02C.0200Wall Construction Standards and that a
If this is a repair;fill out bairn well construction lnf smaltan and explain the nature ofthe copYoftis record has been providedsothewellowner.
repairraderti21 remarkssedian oron the heck ofthrsforaa
&For Geoprobe/DPT or Closed--hoop Geothermal Wells ha _. -r 23.Site diagram or additional well details: • •
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
• FarmoltlplewellslrsraUdepthsldt8ereru(emmple.9[a}200•ardZ@1009 (�) 24a.For AR Wells: Submit this form within 30 days of completion of well • .
construction to the following
10.Slane water level•bebow top of casing:
(fwaterlevel is above casing,use+^ (ft) Division of Wafer Resources, Processing Unit.
f 1617 Man Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 0 rm.) .
24h.For Injection Wens: In addition to sending the form to the address in 24a
YZ.WeD conshaetion method: ' r ��C,'�j above,also submit rate copy of this form within 30 days of completion of well
f°e Y. aditmPasi>etc) • I construction to the following:.
FOR WATER SUPPLY WELLS ONLY: Division of Water Reno ''"
wires,Undergroundt] action Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
6)13a.Yield(gpm) ' Method of tesh 24e.For Water Snook&Injection Walls: In addition i sending die form to.
13b.Disinfec6ion type: 'L. 1l7 7�11!Anaonnt: / ft r tlto address(cs of)elitovc, also submit one copy of this form within 30 days of •
{ completion well construction to the county health deartrnent of the county
where constructed. .ter-
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FormGW 1 North Carolina Department ofEnvuottinetttelQtatity•Division of Water Rsoncees -
Revisal 2-22 2016

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GUILFORD COUNTY DEPARTMENT OF PUBLIC BEEALTI .
Division of Environmental Health,Water Quality Unit
' 400 W.Market St.,Suite 300, Greensboro,NC 27401 -
.R©c©rd of Constr¢ c om, Repallrf or G L and©nrr c r t of a Veen
Address of Well: ,�.r3 9 4rr &i'I3 4-4-5 ep .74 9�,9!�� LATITUDE 3 76' *r o e"
Well Permit Number. - 2^ 8/ ... �n�71N�'-'27Iciffiz . �
Well Contractor Company: *14,g ,,,ell/ Completion Date:6/®S 72,
Total Well Depth: '2- 25‘ ft, Well Yield: r gpm Static Water Level: 30 ft.
Outer Casing Material: y.%(2. / Formation Log
Casing Diameter: �i/$� in. Casing Depth: 7 4 ft. Depth D scripti gry
From: ,9 ft.To:/Z ft. ,/ elet yr
Inner Casing Material: From: 2ft.To:iZ ft. Si� f/ e
Casing Diameter: in. Casing Depth: ft. Fromft.To: 1.2-,t-t. �,- t r>
From: ft.To: ft.
Grout From:. ft.To: ft.
Depth Material Method • From: ft To: ft. .
From: ft.To: ft. From: ft.To: ft.
From: ft.To: ft. From: ft.To: ft_
From: ft.To: ft. • From: ft.To: ft. •
Water Production Zones
Depth: 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 hi effect on this date and at a copy of this record has been provided to the well owner.
Well Contractor: -2 �. Certification ���/ #:2, Date:,,�.//� 72-3
`_rv. ., -..,x.. -L?:arcre r_.s<sC,»-a_-c..w..:._-,v:.t..;�[r.y.���..,.i.:s.•.n.r>.:Y2...g,.yN<:tr:3yS'Y7w'�•<'.Sy+{n;;rla a a,+s :>'bw;c i
Record of. Pump Ensnao®r
Pump Installation Company: c� ; t 1 i Completion Date: 13 Ija--_PumpDepth: �•©CD ft. c0
p Staticrfater Level: ft
Pump Brand: P1® Cs.@. "-a rYN-I, _ (/OS151Pump Size and Rating: 3/1-1 lap /0 gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on th" to an hat a copy of„;,is re ord has been provided to the well owner.
Well Contractor: it l /. _ Certification#:i 'l dig A' Date:
Revised:January 1,2009