GW1--04692_Well Construction - GW1_20230721

Is
I'__
Print Form
WELg'CONSTRUCTION RECORD(CWm11 For Internal Use Only:
1.Well Contractor Information:
David Belcher 14.WATERZONES I .I
Well Contractor Name FROM TO DESCRIPTION 4594-A l g0ft' 1 ft' IO (KPH (3q''nr\ ice.l11
NC Well Contractor Certification Number 165 ft' 170 ft' 11 C• ./4 (,r1 ac,TLtre�
IS.OUTER CASING(for multtrrsed wells)OR LINER(if ap livable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft <Of( it co..2 in' S IW aJ J 'rye
n 1' )�Q ^^ 16.INNER'CASING OR TUBING(geothermal closed-loop) "
2.Well Construction Permit#: rX$•O4•(dAJi`I R•Qo,Pda .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): it it in.
Water Supply Well: 17.SCREEN
Atunicipal/Public FROM ft. TO DIAMETERft. in
m SLOT SIZE THICKNESS MATERIALAgricultural 0
Geothermal(Heating/Cooling Supply) ;-/Residential Water Supply(single) ft ft, in.
Industrial/Commercial _ DResidential Water Supply(shared)
18:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft (ep'en f (Pour t i, h TrucK
Monitoring ORecovery R. ft.
Injection Well:
Aquifer a ft. ft.
9 g ['Groundwater Remediation
Aquifer Storage and Recovery Sal Bather 19.SAND/GRAVEL PACK(if applicable)
['SalinityFROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test f Stomrwater Drainage H. R.
Experimental Technology °Subsidence 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,Gardners sofUroch type Brain size etn)
r O ft. Do clay
4.Date Well(s)Completed: 7•4.o7j' Well ID# ft. f.
5a.Well Location: 68 ft' GT ft' $1 ( ,a, i'{'P.
Chad N,I( rg ft. 1k5 ft' live Gcratl4e
Facility/Owner Name Facility ID#(if applicable) 1 ft ft. C1r J;g 8p n
I E. (-wader (•4, CI.Ceen"Shnr©1 Ilk a7(16 ft ft. N ®�..��d r\�I�
Physical Address,
City,and Zip ft It. •I i i 1 ?-1j 1013
(-f ;IcOrCJ 21.REIiiARKS
County Parcel Identification No.(PIN) brliefltrACieli PftnlleBedtg
i21
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if vell field,one lailong is sufficient) 22.Certification:
Sao is' «.U" N 79° WG' 51.7" W joatIN �3
6.Is(are)the wells) Permanent or QlTemporary Signature of ertifi Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If thls is a repair,fi(1 out known well construction information and explain the nature oldie copy of this record has been provided to the well owner.
repair under 421 renmrks 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 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: I rt'6 (ft-) 24a.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(4)100')
construction to the following:
10.Static water level below top of casing: .`R() (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: (o (in.) 24b.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: ►1(7).1coci :e construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) rQ Method of test: 41461.Thn,t 24c.For Water Simply&Infection Wells: In addition to sending the form to
e the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4TI-1 70 /a Amount: t(ovz completion of well construction to the county health department of the county
where constructed. 1 I
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
",zecord of Construction, Repair, or ithandonent *fa 'Liven
Address of Well: / i I) ('-tanner (4 , (iceensbofo1 MC (971155 LATITUDE a_a_ 13 _ q
Well Permit Number: Q3-O(I- lA.}AUl-a- OoI 2 LONGITUDE h9 LJ(' 51
Well Contractor Company: Ara ONII Xne Completion Date: 7.C�•
Total Well Depth: U ft. Well Yield: gpm Static Water Level: ft.
Ouster Casing Material: lvC Formation Log
Casing Diameter: 6.a5 in. Casing Depth: Cord ft. Depth Description
From: () ft. To: a0 ft.
Inner Casing Material: From: OD ft.To: Gg ft.
Casing Diameter: in. Casing Depth: ft. From: (g ft. To: Cs ft. .
From: cog ft.To: !u5 ft. flue. 6rorn4e
(Grout From: ft.To: ft.
Depth Material Method From: ft.To: ft.
From: O ft. To: ova ft. (Pmen-l- } w:fh Tr c c From:. ft.To: ft.
From: ft.To: ft. From: ft. To: ft.
From: ft.To: ft. From: ft. To: ft.
Water Production Zones
Depth: IaC.? ft.. 1626 ft. ft. ft. ft. ft. ft.
Yield: 10 gpm l5 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: (Davi.01./Laffk, Certification#: Li )4-A Date: T7•ll•(23
Ramat of PallOTIV Insta atioirA
Pump Installation Company: N l ,4 tom Completion Date: it/
j
Pump Depth: I S 0 ft. Static Water Leevel: 0 ft.
Pump Brand: CVO w: �,S 7a M`lQ- PI OSD1 "�( S 3
Pump size and bating: /Li hp I D gpm
Thereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on t 's ate nd that a co f this record has been provided to the well owner.
Well Contractor: Certification#.ac1 -\ Date: /2-
•
Revised:January 1,2009