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GW1--04691_Well Construction - GW1_20230721
WELL CONSTRUCTION i CORD(GW-1) i ' I Print Forrn +� For Internal Use Only 1.Well Contractor Information: David Belcher 14.WATER ZONES _ Well Contractor Name FROM TO DESCRIPTION 4594-A 315 ff. 31g ft WA (Ayr,ittce) ft. ft. NC Well Contractor Certification Number 15.OUTER CASING(for-multi cased wells)OR LINER(if ap Ruble)- Aqua Drill, Inc. FROM TO DIAMETER THICKNESS eI MATERIAL Company Name 0 ft 95 ft. &.^ in, S l I C .16.INNER.CASING OR TUBING�,.a(geothermal:( dosed-loop) 2.Well Construction Permit#: 0{{7-.() •COUNT,- 0l$3( 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 Agricultural gyp, unt aUPublic FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL �7 Clp ft. ft. in. Geothermal(Heating/Cooling Supply) �9)i Residential Water Supply(single) ft. ft is Industrial/Commercial j jResidential Water Supply(shared) 18.GROUT • Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply,Well: 0 ft' ft n Mi 'TrulcY c�� �eP12RE Y(7L(r us Ali Recovery ft. ft. Injection Well: ft. ft Recharge �Gromdwater Remediation Aquifer Storage and Recovery Salmi Barrier 19.SAND/GRAVEL PACK(if applicable) tyFROM TO. MATERIAL EMPLACEMENT METHOD Aquifer Test OIStormwater Drainage ft. ft Experimental Technology (°.. Subsidence Control ft. ft ' Geothermal(Closed Loop) OTracer 20.DRILLING:LOG(attach additional'sheets if necessary) - Geothermal(Heating/Cooling Return), (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,so30mcktYpe¢taia sire etc.) 0 ft. nvo ft. (ice 4.Date Well(s)Completed: 6-,2?• Well ID# ego ft. 550 ft (Df SQRe) ' Sr);) 5a.Well Location: 50 n. 90 ft. Sd ( 50 (l CtcKt/Ofi Ci 'IleS clent;cil 1)1,610ers 90 f 95 It `llue ay.(1ke ra Nab Facility/Owner Name Facility ID#(if applicable) CAS ft 3145 ft. 'blue �K cn.Llike I A" r".G 9515 L QdK 'Dcitvv. 1 Cr, zt 1 fiX 6r7,7R5 ft ft. Jul 9 1 7023 Physical Address,City,and Zip ft it l�(�1l"SofS 21.REMARKS, _ • f�F 1ri mite I)Prr::�awvr*S. County Parcel Identification No.(PIN) Pltitai5 Oc L5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - (if well field,one lat/long is sufficient) 22.Certification: 3fe° ?' 65.1i" N g0° Or 6.4D w ID-uA. 1 ----, . 6-30-t23 6.Is(are)the well(s) Permanent or Temporary Signature ofCertified.Well Contractor Date By signing this form,I hereby cert�that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: Yes or with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200.Well Construction Standards and that a Ifthis is a repair,fill out known well construction information and explain the nature oftlre copy of this record has been provided to the well owner. repair under#21 remarks section or an 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 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: 3115 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths ifdijferent(example-3@200'and 2@100) construction to the following: 10.Static water level below top of casing: 5'0 (ft) Division of Water Resources,Information Processing Unit, Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: �jt n ' (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a 12.Well construction method: l (� �;( above,also submit one copy of this form within 30 days of completion of well (i.e.auger,rotary, construction to the following: g cable,direct push,etc.) g Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS/� ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 636 13a.Yield(gpm) 6t r/-1 Method of test: CrAdfl 4.-vpie 24e.For Water Supply&Injection Wells: In addition to sending the form to o the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: HYH 70// Amount: 1(QQL 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 IEALTH Division of Environmental Health,Water Quality Unit 400W.Market St.,Suite 300, Greensboro,NC 27401 Record of Construction, Repair, or Abandonment of a Well Address of Well: g515 'S n OA ' rue, („olcog, Jur a'7,235 LATITUDE 3(o , T] 55 .. R' Well Permit Number 017-OO-VOA-01 Co LONGITUDE $0 n © . 4 Well Contractor Company: abuts 0611 .xnr. Completion Date: (Q• f.a3 Total Well Depth: 3145 ft. Well Yield: a0 _gpm Static Water Level: 50 ft. ' Outer Casing Material: (91)C Formation Log Casing Diameter: Co.al in. Casing Depth: Q5 ft. Depth Description From: D ft.To: 00 ft. Inner Casing Material: From: 90 ft.To: 5( ft. Casing Diameter: in. Casing Depth: ft. From: 50 ft. To: QO ft. ,• From: c/o ft.To: cl5 ft. 1 Groat From: 95 ft. To: 345 ft. /1ue C coc*e Depth Material Method From: ft.To: ft. From: 0 ft.To: c23 ft. (te pc4 (Pour Ian rcuck From: ft.To: ft. From: ft.To: _ ft. - From: ft. To: ft. From: ft.To: ft. From: ft.To: ' ft. Water Production Zones Depth: 31 ft. ft. ft. ft. ft. ft. ft. Yield: a0 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: Orwa 91.0.P.A Cr, Certification it: LJt114-A Date: 6.30. 013• • Record of Pump Installation Pump Installation Company: Pv Dr a I — .�L '7 c Completion Date: 1 )i7-. r Pump Depth: c,9.5 0 ft. Static Water Level: 'LiC) ft. • Pump Brand:�r-LA-. -A aD S Q. 10--i 9 0 Pump Size and Rating: i hp sic. gpm I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well Rules in effect on this ate that a`cop of • record has been provided to the well owner. Well Contractor: - Z7 Certification #.� Date: 7,4/23 G Revised:January 1,2009 1