GW1--07401_Well Construction - GW1_20231117

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.WELL CONSTR
UCTION•RECORID(GW,1) • . For Internal-Use Only: • •
1.Wel Contractor Information: •
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14.WATER ZONES :1: •
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Well Contractor Name FROM•_ TO'. . ": DESCRIPTION
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2080-A. j ii 6 fi. 1.,e11 .ft.• ,361",6.1 pi,f •N 1.'. . .... . .
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. NC 1:vell Contmcior Certification Number.
15.OUTERCASING(for mold-cased wells)OR LINER, f:ap licable)
. •Aqua Drill,•lnC. •• FROM TO I- ' DIAMETER :THICKNESS "MATERIAL .
Co'npaa, Name' ' . • h,0 . ?Di
O. _ft I ��..tt.." Sf O. .5'IYJjL�I 4e
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y� �J •
y 16.INNER CASING✓OR TUBING(geothermal.closed-loop).•-
2:Well oristruction Permit#:2 3 -C).,a( '•V N.14 FL.00 LI 3R011. .TO- :DIAMETER THICKNESS DIATFRIAL "
List di appitcnble irsll cans:racdon permits(i:e.UIC.•Count•,Sink,;Variance:etc.) •' ' Ft. ft. •'' ' •"in.
3.Well Use.(checkai'ell use): . .. . • fL •'• ' •in.'..
Water apply Well: . • ' - : . .: • 17:SCREEN :
'FROM': ' TO" . ' 'DIAMETER' SI OTSIZE' THICKNESS' . :MATERIAL Agric Mural OMunicipaVPublic: : .: - . : ft. . . ft. " in. • •
Georh anal(Heating/Cooling Supply). Rcstdntt eal Water Supply.(single) " "•
ft.' ft: In.
Indu. ieliCoMmercial • • . QRcsidential Water Supply(shared)
18 GROUT•
Nisi-, M Supply Well: . ' ;
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Montt fIring
Rccovcry_' ' •
�FRO\'t ft.....I ft.
�
e
IV �u
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nandtn "19.SAND/GRATVEL•PA CKk-M AT ERWLe " .• EMPLACE5E TMETHO D•&_A•
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MOUNT
lnjectio Well: : " . ' • • -:ft. .' „Ft.•A lntf rRecharge . . LiGinudwtermao . • " •
Agntt`r Storage and Recovery Salinity ' .
FROM TO .I MATERIAL - 1 •FSIPLACEMFNTMETHOD'...... '
Aq:it .1 est DStormwater Drainage ft.f, ft:
rxperi items!Technology' ' ' :Subsidence Control ft I ft.
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Georh anal i Closed Loop) DTracer ' • 10.DRILLING LOG(attach additional sheets if necessary)- • -
' "- Gentn ratal'(1-leating/CoolingReturn): .JlOther(explain;under421 Remarks). tR°a1 TO "• •DFSCR1PTtoNMotor•barancss soiFrocknpaaratnsire,etel' .
ft. Ft _ "..
^. ;Date refits)Completed I i''�' 4 3 Well ID#J ti41':r eL 7:• 'fr. ft : SA IN& 2�
�. Fr..l. 8'
� 13 lase• � 1t�i4•
ri� �.
ft.
FLili' O ic-Nisis' .: FacilitylDO(ifappliaible) : ' ..ft••1, ft. _ •r , t - "
Ci:s• Fn 1." it
P.,v,l�a Ores;.City.anazjp: • : - - . • • : : it ft ' - - NOV • �_.- .. • •
Len
zr REit7ARKS
County.: ' " ' .ParcclIdentificationNo:(PIN) • liai�l •.
:• •Sb.Lai;ice and longitude in degrees/miliutes/seconds om decimal degrees:.
(ifwcII flu d.one hulling issofficicnt) • • • . • 22:Certification:
?� .W afi:4:1
6.islare)the st e!l(s 4"ermanent or.Temporary . Stgnatntc of Ccn tfi ed Well`ontiactor Date
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By signing tlti.,farm,I hereht•rerilb.that MU lrelks)was(here)eansinit•letl in accrirdatce..T Is twit ‘i pa,-to an existing well:. [t es or o - wil 1S f 111C4C(PC.0101[or%SA NCAC 0?C.0200 Fell Cmrsirircrinn Standards and thai 0-'•
!i dtit 4.r ,ap;ilr,fit!tint knou;i itrll cmtcgvcout,infra ttution and caplaln ilia armc s of the cipr ofdds rtrnrd has heen pi in tdcd to'thc wall(Aner.
' repair:inn) .-•11 remarks set•tatn at•an die bad ofth/s ftlrnt. • . .
23:Site diagram or additional Well details:
S.Fein C,6probe/OPT or Closed-Loop Geothermal Wells having the same You may use the back ofthis page to provide additional well site details,or"well..
ceps Ltti:•-only1CiW-I-isneeded. IndicateTOTALNUMBEROfwells construction details..You may also attach additional pages,ifnecessary.' '
drilled:
• 'SUBMITTAL INSTRUCTIONS
9.Tot:t1 t all depth below land surface •
• ) • (ft•). 24a. '*or All.Wells: Submit this'form within.30 days of completion_ of'tvell
Farr ne1 •..:Its Itst till depths ifdiifferent(etanple-3(ri;200 100')'and 2@ - " -
construction to the following 1
I t).4rai:l'Water level tielox�top of casing: 3 O.
Ifwati't:het ;',plyn... •
el bob nee••_ •
(ft.) Dfi'lslon of Watei Resources,Information Processing;Unit,
1617 Mall Se trice Centcr,Raleigh,NC 27699-1617 •
Il.Burs!sic diameter: .(in:)
26b.F Injection Wells: In a .. m to sending the fornt.to the address m 24a-
orddtho
12.\i ell construction method:•A , .,� • above:also.submit one copy of this'form within 30 days of completion of well. •
(i.e.;it e s.:r,,cable,direct push.etc.) construction to the following:.
Division of Water Resources Uder' un •
n od In ection Control Program,FOR::V::i i:R SCPPLV WELLS ONLY: '- • - 'l Service Ce 1 ' j `
1636 Mail Raleigh,NC 27699-1636
132.='iei( i^,pm)__2d.• • Method of test:•$l'Ct k 4 . . • 24c.For Water Supple&Iniectio l Wells: Iti addition to sending the form to the addressies)above; also submit lone copy of this form within 30 days, of
• 13b.?t',i^"s rraon type:_14,Tfl .Amount:•
.6- ' completion of well construction to the.county health department of the county
. •- - where constructed.
Furs'.C."i-. 'North rimy-din:,n....onm.,t is r....:.,..,...._...1 r,..-,:... ...-__• .... ..

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit . : : . .
: 40. W:1VIarket-St;;Suite 300, •Greensboro,NC 27401 : • : : .
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Record of Construction, Repair, or Abandon{ment of a Well .
Ad• ress of Well / 2 ! ,
6� : .I oc r`7c , 1Zvn LATITUDE 3
We I'Permit Number 21" O
'4.A.1 4)2 *Cho 3 4:3 LONGITUDE � '
Well Contractor Company : Aqua Drill, Inc.: , . :
' : Completion pate:�l!-��S
Total Well De th :I`3. :ft. � Well Yield:.3 A 3_O .
� _gpm : Static.Water Level ft. ' , '
: • Out .Casing : • :Material 51)1Z 2 i P 9.1J,C Formation Log
Casi g Diameter: io. Casing Depth. 75-. ft. Depth . Description
%y.
Inner Casein : . Material. From ft. To;. ft: .
g , .
. From � . ft To , .. ft•
Casing;Diameter: . in:. . Casing Depth. : . ft.: From 70 ft:To '!S'ft: .3) .L-ru nu i;,c - ,
: :
• Grout
ro m o
. From. i .: ftTo . � ft.� � � .
. . '. . Depth : : Material :: Method : : . From...I it:To ' ft,
From:0 _ ft..To . .
ft. ��I�e�� . •Ttze�CK From: I�� ft.To: ��ft. ..
: : -From ft..To ft. . • .'. . : .
From:_. . ft:To: .:.. .ft: _ .. .
Fioin:��.k � ft.�To ft.
Froin:� ��
.�ft. To: ft
Water Production Zones
De th E LI O ft. ft. . .
P ft. ft. � ft:
ft:. . . ft: -
. . : Yield:. RU._.: gpm gPm � : � � gp.m � gpm1 gm � .
• .gPm :gpm
Method of Repair: .. : .. -
:. -Methpfl of Abandonment: . .
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I hereb certify that this well was constructed,repaired,or abandoned according to the Guilford County Weil l
Rules i 'effect on'this date and that a copy of this.record has been. provided to the well owner: - :
Well Contractor Chris Ki•ng L% �`l 208U_A
�� Certification#:� �� Date•�J)- 2�' 2 3
Record.of Pump Installation: : . .
Pump, stallatlon:Company: /7gr-1i? JdJLL Z>2-'G .. . J Completion Date
: y/4/./-if . - .r.
Pump Depth: /10, ft.: Static Water Level: II F ; ft. -:
Pump rand 2O4J,S4 / $40 7. Pump Size and Rating: z'iSi hp ' •60-. gpm
I hereby certify that this•pump was installed:and wellhead completed according to the Guilford_Count, Well
Rules it effect on this date and. that a copyof this record has been provided to the well owner: Y,
4e p /
Well C ntracto' ," _ . Certification#:a fo �2C-Date /��: 043
Revised:January 1,2008