GW1--05583_Well Construction - GW1_20230825

WJYA,CONSTRUCTION RECORD(GWIl) For Internal Use Only: Print form
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A /6Oft /6 f ft 6,1 P, -
ft.
NC Well Contractor Certification Number ft.
IS.OUTER CASING(for multi cased wells)OR LINER(dap llcable)
Aqua Drill,Inc. FROM /TO /DIAMMETER' THICKNESS g MATERIAL
Company Name / -^ 0 f (C?d ft 67cf ➢n. 5j✓)Z2 1 I I`'i V C
-.1 .. t1Z.-o®a2�S 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:2.-6 FROM TO DIAMETER! THICKNESS MATERIAL
List all applicable well construction permits(e.UIC,Cannry,State,variance,etc.) ft. ft. ➢n.
3.Well Use(check well use): ft. ft. in.
Supply Well: 17.SCREEN
AgriCglturalWater.Su FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Municipal/Public ft. ft. ;a.
Geothermal(Heating/Cooling Supply) Zigesidential Water Supply(single)
R. R. In.
Industrial/Commercial °Residential Water Supply(shared)
Inigation 18.GROUT
FROM TO MATERIAL EMPIJ CEMENT OD&AMOUNT
Non-Water Supply Well: 0. R, 20
n, Cc � 1 T I IZU C'IC
Monitoring °Recovery -CJ ft. 1
Injection Welk
Aquifer Recharge OGroundwater Remediation R. ft. I
Aquifer Storage and Recovery Salmi Barrier 19.SAND/GRAVEL PACK(if applicable) -
ry i FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test f°StormwaterDrainage R. ft.
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING.LOG(attach additional sheets if necessary)
Geothermal(Iieating/CooliagRetrrn) Othr r(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardens.salYrocktyae.grain sloe,etc.)
q !� © ft. � ft. �,e C
''
4.Date Wells)Completed:?-o� 7--23 Well l 4.15.4 .2„.2. 6 ➢t 55 ft 5�o d' . c(,
Se.Well Location: 5 5 'B. J SS-R. Mu el 6-iziovud e.
ft. ft. !
Facility/Owner Name Facility ID#(if applicable) ft. , ft. ,
(3 PP&rPS //4/2. it. ft F r, �.m
k'�t� ��
Physical Address,City,and Zip ft ft. m" "®" Vl �
6011ITO/2J 21.REMARKS AV(.i ZU2 5
County Parcel Identification No.(PIN)
Six Latitude and longitude in degreeshninutes/seeonds or decimal degrees: Irl;zlfwr.adC PP^C446i:fSg Un.
(if well field,one latilong is sufficient) 22.Certification: j pie"1..�a
N
W �• 7-2 3
6.Is(are)the well(s rman t or Temporary Signature ofcertiri d Well Contracto Date
By signing this form,I hereby certifr at the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes on .!No with 15A 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 ofthis record has been provided to the well owner.
repair under#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 OW-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 O !
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) ( ) 24a. For All Wells: Submit this foim within 30 days of completion of well
construction to the following.
10.Static water level below top of casing: f ''
lfwaterlevelisabovecasinguse"+'- ( ) i.
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 296991619
11.Borehole diameter: S4 (in.)�j 241.For Injection Wells: In additiot'to sending the form to the address in 24a
12.Well construction method I�2 (,'/� l � above,also submit one copy of this form within 30 days of completion of well
•
(i.e.auger,rotary,cable,direct push,etc.) construction to the following: j
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
e 11636 Mad Service Center,,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 51 el)'b 24c.For Water Supply de Injection Wells: In addition to sending the form to
p the address(es) above, also submit one'copy of this form within 30 days of
l /
13b.Disinfection type:�`-4 Amount: 4 d Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of linvironmental Quality-Division of Water Resources Revised 2-22-2016

- I
GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Uriitj
400 W.Market St.,Suite 300,Greensboro,NC 27401
Record of C®e structi on, Repaior t, or Aband:mini ergt o Well
Address of Well: C 53 6 go9 e 12 S Fp9 pile% LATITUDE 3
Well Permit Number: d 3-0 S. N '--o•Da5's
LONGITUDE
Well Contractor Company:, i4 j
Completion Date:
Total Well Depth: _ft. Well Yield: 3
gpm Static Water Level: 3 o ft.
Outer Casing Material: Pi(I, (,
Casing Diameter: C i//9 in. Casing Depth:60 ft. Formation LogDepth :Description
From: 0 ft.To:
InnerCasFm _ft. �o
g • Material: Depth: From: ft.To:5'S ft.
Casing Diameter. in. Casing D tIr: ft. From:55'ft. T o:/5S`f t ���� Roc K
. Lei A'��•��
From: - a�
M
Depth Grout From: ft.To: ft.
From:- Material. Method From: ft.To: ft.
0 ft.To: A2 6 ft_ crizucK. From:
From: ft, To: ft.
it.To: ft.
From:
From: ft.To: ft, ft. To: ft.
From: ft To: ft.
• . Water Production Zones
Depth: /CO ft. ft. ft. ft
Yield: 30 gpm m ft. ft. ft.
gpm . gpm °pm gpm gpm
Method of Repair:
1
Method of Abandonment: i
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: e/h...;
9,..„.:C State Number 0 Sb a
A Date
Record 2j((,yy,�,,��-1ffS4'�f��..,.,.,Pump
}���y {�ry��r��{{��/c{�� }q�
.. ' r `+ ��YIYI of �`.� �� LLtS� ISGiYi(WiS®f �,V.
Pump Installation Company: f\-yyq ` UUUI
.1'�� 1� Completion Date:1
Pump Depth: I D(� ft. Static ' ate r Level: �gfrj >t.
Pump Brand:- (cuo(5e., i Cri 1 -PI OS)7 uutnp Size and Rating:1 .t �j
hp � C./ gpm
I hereby certify that this pump was installed and wellhead completed accordingto
Rules in effect on this date and that a copypthe the owner. County Well
of this record has been provided to well owner.Well Contractor-Contractor 1 A
�q 2�� G�Ss-'�`—' State Number Lp7 7—. Date: i i? (:)--