GW1--00938_Well Construction - GW1_20240209

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WELL.CONSTRUCTION.RECORD(GW l) - For Internal Use Only: i ('I
1..Well Contractor Information: I
Chris Xing , . 14.WATER ZONES .: . . -,:I- '. -' . _ • _
Well Contactor Name • FROM TO DESCRIPTION
2080-A r.go.it. /Cfi � .tl:. - /0 i G t t ri.
ft: -ft.• I
NC;Well Contracto•
r Certification Number MOM-easedIS.OUTER CASING(for MOM-eased wells)OR LINER(If ap liable) '
Aqua.Drill, Inc. : FROM . TO DIAMETER THICKNESS.' •':ft -MA R�IAL• . ..
Company Name e)'. it. . 45 . •/ g.i In., 5,)`2�.t .rI tom•p/c. '
.
'16.INNER CASINO OR TUBING{geothermal closed-loop)
2.Well Construction Permit#i 't..I j'U '. F, FROM - ' -TO ' DIAMETER.' -THICKNESS ..MATERIAL
List all applicable well construction permits,(Le:UIC,Cowry,State.Varlance.'etc.). ft...' ft. ta.'
•3.Well Use(check well user ft. tt, In:
Water Sby ppiWell:
A Cllhural FROM' TO . • ':DIAMETER' .SLOT SIZE• TIHCKNPSS • MATERIAL- .
Q bm QMunicipal/Pubiic fr.•• ft In.,
DGeothermal(Heating/Cooling Supply)'0,EesidentialWrnerSupply(single)
• :Dlndustrial/Commercial DResidential Water Supply(shared).
9&GROUT_:'
J irrigation'. FROM ' TO • MATERIAL -- 'EMPLACEMENT BIETHOD&AMOUNT
:Non-WaterStipply-Well:• . •® fL -26 ,ft.. dei4ie'03T . Tit-oct 0Monitoting:, , DRecovery. . .' . . ft: 'ft
:Injection Well:
DAquifcrRcchargc' DGroundwatcr Remcdiation ft�' R'
Aquifer Storage and Recovery Salinity Bairier 19.SAND/GRAVEL PACK(if applicable) -
FROM' - TO -MATERIAL EMPLACEMENT METHOD
Aquifer-Test Stormwatei-Dminagc. R fz" '
ExperimentalTechnology :DSubsidenceControl • .R. .it.
Geothermal(Closed Loop) DTracer ':20.-DRILLING LOG(attach addlilonalsheets if necessary) ' :: - . -
Geothermal(Heating/Cooling Return): :�I-"4Other.(explain under#21 Remarks). FROM • TO .DESCRIPTION(color haninew;esIVmckh se,grain she,ek) .
t3 t . a ft. . ft Rem+. .�:1 gi-
-
d.Date.Well(s)Completed:) R yell 1D!/ ' I fu' -�. �o. ft. SAs ;d,. 1z4GJl .
•
Sa:,Well Location: e.
90' . �ClS f`.. 13IuG. 6 2Aru l.4e ,
•
in ems.
Facility/Owner Name -Facility ID/1(Ifappllcablc) ft.- .ft.. . • 'd'" — '
.Ll:`.7 ma's6e yc .i7 . 6.4e r�Sbo12:0 - it: ft: LB 0 Z024
Physlcal-Addtess,.Cily,and Zip R. ft. •: u
�'e t • 21.REMARiS. , Ilf:•
FCt
V eiiI • • C`
County .Parcel Idcntificatlon:No.(PIN) ^ •
.Sb.:L'atitudeand longitudeln.degrees/minutes/seconds'or decimal degrees:.
(ifwcll field one tat/long is.sufficient) 22.Certltl atlon:. i
•
N. �,'//�
/�
W 1 - 1q-7 :9
-6.Is(are)the.well(s) rmanent, or,:OTemporary,. Signature of C fied:Weil Contractor Date
By-signing this jiim;I-hereby c rtlfy that the ne//(s);tivs,(were)cons(rucled:in accordance
7.Is this a repair to an existing well: •DYes.,or,IVo - - atlth.154.NCAC 02C.0100 or 15A NCAC:02C.0200 Well t:onstritcllon Standards and that a•Ifihis is a repair,fill Out known well construction L fornmtinn and rplain the nature of the Copyof this record has been provided to the well owner:
repair under#21 remarks section oroii 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.
construction,only•1.GW-I 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•surfacer i�.�1 J • - (ft.) -24a. For.All Wells:. •Submit:this form.within.30 days'of completion'of•well
For multiple.wells list all Oinks If,dtfferent fexaaipie-.3@200"and 2@100�
construction to the following:.
10.Static water level belowtop.of casing: 6'a (ft.
If water level is above casing,use•+^ ) Division of Water Resources,Infarmetiou Proctst;ipg Unit,
1617 Mail Service Cetiter;.Role(gh;NC276991617
I1.Borehole diameter: `P (In.). 24b.:For 7niection-Wells:.:in addition.to sending•the:farm to the address in 24a
12.,We11 constrnctlon.method:. above,also submit'one copy of this"form Within 30.da of completion of well
dl .IZ . l"Ts;) Ys p
-(i.e.auger,rotary;cable;:direet push,etc.) CotistlUCtion to the following: i
FOR WATER SUPPLY WELLS ONLY: w t Dlvieion of.Water Resources,Uniderground Injection Control Program,.
. 4 /y . -1.1636 Mail:Service Center,Raleigh,NC 276994636
13a;Yield'(gpm). __I'.0. 'Method of test: - .24c.For Water-Supply&Infection Wells: In addition to_sending the form.to
the•address(es) above,.also:submit:one Copy of this-form within•30.days-of
• 136:Disinfectiontype: 't7 1 17 'Amount::/ - [) e—. -completion of well.construction.to the county health department of-the county-
where constructed.
Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016

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GUILFORD COUNTY DEPARTMENT.OF PUBLIC HEALTH
Division:of Environmental Health;Water.Quality Unit
400.W:Market St.;Suite 300;. Greensboro,NC 27401
Record of Construction, Repair; or Abandonment Of a We
ll
Address of Well. • i -� s �n51 �,
-LATITUDE-3
Well Permit.Number:.1'-i -m / i i I-1jZ
Well-Contractor Company Aqua Drill; :Inc..
' -
.: :Completion Date:/ ';29-.2:4 - .
:Total Well Depth: _ft.. Well Yield:/6 gpm : .Static Water Level:,Co . . ft.
Outer Casing. Material:
Formation Log . •
Casing Diameter:.6 /c).' : in:. Casing Depth:. �� . ft. Depth
l? Description
From:6 ft. To:3 ft.. Rr4i.f C I1/Y
Inner:Casing Material: ft:To
Froth:"
.. 9b ft. .
Casing:Dlarnteter:: in: . Casio -5�i rud :I Zc►G it.g Depth: ft. Froin:q(� ft,To I S' t. 13k.c C-fz ln.l i3C
From:. ft::To: ft
Grout From: ft.To: ;. ft..
De th / Method: From:- ft.To:: it:
P Material
From; D ft.To: :0 ft, eol ft:To: ft.
Prom � ��C- '� ����Zcae''i�. . �From: �
ft.:To:. ft:
f
:From: . . . .ft.To;. � ..
. From: . L To: ` ft.
ft: From: _ft:To: .ft:. :
Water.Production Zones I
Depth: it/O.:.ft.. . :ft; _ft.. ft.
Yield:. � . � . ft. '` ft. - .ft;�.
It) .gpm. m .
gpm gpm gpm gpm-. gpm
Method of Repair
,
•
Method of Abandonment:
I
I hereby certify that this well was constructed,repaired,or abandoned according to the Guilford County Welt.
Rules in effect on this date and that:a copy of this record has been-provided to the well owner..
Weil Contractor: •e4205
tr . . Certification#: 2080-A Date:/ •—. 9 -
Record of Pump 'Installation
Pump Installation Company �. l f
r Completion Date: , t 3i "�
Pump Depth: 5.0 :ft:: Static' Water Level: . �1. ft.
Purrs Brand: ..LA.K.S.e.. i.Ar1r ' ,4l OSC` . :Pump:Size and Rating: ! '3):
I y hp. 1. (� gpm
I here certi
yy Mils pump was installed ed and wellhead completed according.fo the Guilford County Well
:Rules in effect on• is e that a copy of this record:has been provided to the Well,owner.
Well•Contractor. f. .i
:
'� Certification#: t P.{ . Date•.2+ /Z.
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Revised:January1,2008