GW1--06647_Well Construction - GW1_20231017

i
WELL CONSTRUCTION RECORD(GW-1) _ Print Form
For Internal Use Only: .
1.Well Contractor Information:
David Belcher 14:WATERZONES .:
Well ontractor Name FROM TO DESCRIPTION
45 4-A IsO ar Kg ft aO}C M (Crnc.iuce)
ft. ft.
NC Well Contractor Certification Number
Aqua Drill, Inc. 15:13UTER CASING(for mull-eased wells)'OR LINER(if ap livable) '
FROM TO DIAMETER THICKNESS MATERIAL
Company Name tJ ft. I mg' it 16 a5tn• siX101 Ti vc
2.Well Construction Permit#: (�7.03•(4)AMR-f70 �7 `i6.INNER'CASING OR TUBING(geothermal closed-loop) '
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft In.
3.Well Use(check well use): ft. ft. In.
Wirrtlr Supply Well: 17 SCREEN• .;`
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Ag-icultural !°'MunicipaVPublic ft it in.
Geothermal(Heating/Cooling Supply) P°Residential Water Supply(single) •
tt ft in:
°Industrial/Commercial °Residential Water Supply(shared)
hri flation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-"Water Supply Well: �y /1 �y ft.
( M I itonng Recov V ('ealerr4 out' l�):�h 7fufK
Injec Ion Well: ft ft.
D .ifer Recharge Groundwater Remediation ft. ft
°Aq ifer Storage and Recovery i°Salinity Barrier 19.S�/GRAVELPACK(If applicable) -
FROM TO MATERIAL EMPLACEMENT METHOD
µ
DAquifer Test °StormwaterDrainage ft ftu
°Experimental Technology °Subsidence Control It ft
°Geothermal(Closed Loop) °Tracer 20:DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness.soil/rock t)pa,grain size,etc.)
°Geothermal(Hcating/Cooling Return) °Other(explain under#21 Remarks)
ft. ft
4.Da'e Well(s)Completed: 7.&•a?3 Well ID# �n rt � tt sandy i I
5a.Wien Location: i13 ft 114(' ft. rue' etral/ �e
Ctptilald (trahrxln t i 8' ft. (9 5 ft'
tue Gcrallncfe
Faccinilit'/Ow/neer Name
n (� (Facility ID#(if applicable) ft ft
1� YIIS fl Y1I t1C] ft ft
Surnplertie0j tic R935�
Physial Address,City,and tip t[. ft r -,,r:- ;i .�
( ,;21. - i=
- C1lll,�000REMARKS,._ r t S
County Parcel Identification No.(PIN) u L I 1 1 ��I«•
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: )rvf,-,r -</:'l 73":=:%"?.;.:f ri I. .::
(if well field,one lat/long is sufficient) 22.Certification: o'sCl/3 0C
3� II' ur.3" N 79° Gal 32.9" W J o
6.Is(a e)the wells) Permanent or °Temporary Signature of Certified 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: °Yes or : No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to thl well owner.
repair nder#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
cons ction,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: a05 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdj5erent(example-3@200'and 2Qa 100)
construction to the following
10.St tic water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
If wate level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Bo ehole diameter: (0 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.W 11 construction method: fYtct7 it{ above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
nf 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Y eld(gpm) 'QC) Method of test: &kb.+11 e. 24c.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.Dfsinfection type: IdTN 90 /p Amount: Ll'gC9Z _ completion of well construction to the county health department of the county
where constructed.
Form G1V-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

GUIL.FORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality 4nit
400 W.Market St.,Suite 300, Greensboro,NC 27401
Record ,,,f Constralictoono las aaru or Abandon a -.ent of a !ell
Add'ess of Well: )00 QrncK l�: e I ), Simniec(?p1d,)UC 077855' LATIgUM kft_ lI 41 3
Wel Permit Number: 45-01- W I1P -oov$7
Lt:ITU®E 74 5a 302 Q
Well Contractor Company: ArDun '1c��fI Inc Completion Date: `7• .a3
Total Well Depth: 0705 ft. Well Yield: �n gpm Static Water Level: ft.
Ouster Casing Material: PVC For.vealtiO.P Log
Casing Diameter: 6.0 in. Casing Depth: II ft. Depth P Description
lfnanne CasingFrom: C) ft. To: (lc) ft.
Material: From: 0o ft.To: itS ft.
Casin Diameter: in. Casing Depth: ft. From: tlg ft.To: i is ft.
Depth
.l~rom: i Is' ft.To: .20.5 ft. /wo.C•crnn:!e�
(G>r®ant. From: ft. To: : ft.
Material Method From: ft.To: ' ft.
From: .To: o?y ft. r Rf Nair wS•ih TrucK From:. ft.To:
From: ft.To: ft.
ft. From: ft.To: -ft.
From: ft. To: ft. From: ft. To: I ft.
Water PrPodunetiona Zones
Depth lec ft., ft. ft. ft. ft,
� gpm ft. ft.
Yield:
gpm gpm gpm gpm gpm gpm
Methodof Repair:
Methoil 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 or this record has been provided to the well owner.
Well C ntractor: gavel) War Certification#: Ling-A
Date: 9•l l•p8
Pump Installation Company:
Completion Date:
Pump Depth: ft. Static Water Level:
ft.
Pump rand: Pump Size and Ratinlg: hp gpm
I hereb certify that this pump was installed and wellhead completed according to i he Guilford County Well
Rules in effect on this date and that a copy of this record has been provided to the well owner.
Well C ntractor: Certification#: Date:
•
.- Revised:J nuary 1.2009