GW1--04438_Well Construction - GW1_20230710

I Fruit Form
WELL CONSTIRUCTION RECORD(GW-1) For Internal Use Only: —
1.Well Contractor Information:
David Belcher 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4594-A ISO ff' 133 ft 3()(014 Track t00)
ft. ft
NC Well Contractor Certification Number
15.OUTER,CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS g MATERIAL
Company Name Q ft.
83 tt G.a5 hi' 59g o?l I rPt)G
n 16.INNER CASING OR TUBING(geothermal closed400p)
2.Well Construction Permit#: ,,,9 -oa-W/U N P-Oc)I W '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. in.,
Water Supply Well: 17.SCREEN,
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
°Agricultural ° umctpal/Public ff. ft. in.
°Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ff- ft. in-
Dlndushial/Commercial °Residential Water Supply(shared) ,18.GROUT
flirrl'igation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ff. it t-
3� CeMPWE Pair 14-h -rcuc
(Monitoring °Recovery ft. ftK
Injection Well:
fG ft.DiAquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) ,
°Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test - °Stornwater Drainage ft. ft.
Experimental Technology °lSubsidence Control ft ft
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type quoin size etc.)
O ft. n© ft a4.Date Well(s)Completed: (.�f(-AWell ID# �i _ 10 �0 ft. N.75( ft
Sa.Well Location: n fL $3 f' true. &•Qngi°-'--,w E; f i?`•`'•
Homes (Slue cirr5nrt1t-
Facility/Owner Name rr n 1 Facility ID#(if applicable) ft fL II Ir i O 2(171
(1,rt1 LI)(n51t7 r5 Jarin P' )t ?lea�tnk(-ta!'r}enlNG ft ft. J'J Y v — ..
Physical Address,City,and Z .97313' ft. ft. •��;3 t• -�,;,�•.,. t.r eA
InIz rit::yt F. .^,
�!(�1 jrJ 21.REMARKS,. lam` .:.hc-'
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.CCertification: ;
35a 5/11 35 5tt N 790 uG' I.`'(" w ()0tr e: ;tL—_ G-.26-0 3
6.Is(are)the well(s) -- Permanent or °Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: °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 of the copy of this record has been provided to the well owner.
repair wider#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GiV-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: J Lp 5 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(([different(example-3@200•and 2@100') construction to the following:
10.Static water level below top of casing: UQ (ft.) Division of Water Resources,Information ProcessingUnit,If water level is above casing,use"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: In (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
I
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: cr}Cllfy Air 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) 7i() Method of test: Cal A- -11 lh a 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: I-ITt•t ' C'/n Amount: I(or . 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

1
GUILFORD COUNTY DEPARTMEN1T OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W. Market St.,Suite 300, Greensboro,NC 27401
'record of C©nstractoo a ( epairo or Albandon gent 11 a Well
Address of Well:(�,,4 10 65147 I360icS V.I.rtrt T))(Plea5nd- Clac-Jen 11J . LATITUDE 3,5__ 54 3S o 5
Well Permit Number! c23-0a-WJUH''-o01`7-1 LONGITUDE '79 L)CQ
I oR
Well Contractor Company: Avo (0c;Il Ync• Completion Date: G-ay• R3
Total Well Depth: I65 ft. Well Yield: &) gpm Static Water Level: t(p ft.
Outer Casing Material: (PUG Fotmatio+e Log
Casing Diameter: 6.g5 in. Casing Depth: $3 ft. Depth Description
From: 0 ft.To: DO ft. Clack
Inner Caen Material: From: o?n ft.To: ft. M
Casing Diameter: in. Casing Depth: ft. From: S' ft.To: g3 ft. 1i lu C-cranl+e
From: F 5 ft.To: )Co5 ft. 'lire C•csanl+e
Grout From: ft. To: ft.
Depth Material Method From: ft. To: ft.
From: 6 ft.To: 9 ft. Centeno e c' t ;Tl1 TrucKFrom: ft.To: ft.
From: ft. To: ft. From: ft.To: ft.
From: ft.To: ft. From: ft. To: ft.
Water PirOduction Zones
Depth: 13O ft.. ft. ft. ft.
ft• ft. ft.
Yield: on gpm gpm gpm �m
gl 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: (l),u,r,O %,240t, Certification#: 1-15gU-A Date: Co- -a
...T'.., -,, max „ ,z. ._ _
R coll'c`l of pump ErosfannatNon
Pump Installation Company: i t\ Completion Date: L .��1. j
Pump Depth: t 0 0 ft. Static Water Level: -O ft.
Pump Brand: -PA°L . -1 riria, P1 O56 Pump Size and Rating: -3 19 hp I t gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
71 Rules in effect on this ~_e and •it a copy of this record has been provided to the well owner.
Well Contractor: _ i..--z ' l Certification# "1°4). Date:
•
- Revised:January 1,2009 .