GW1--02762_Well Construction - GW1_20240506

WELL CONSTRUCTION RECORDG . [V,r..Print Form
1 For Internal Use Only: '
1.Welt Contractor Information: '
T
Gary Thompson 14.WATER ZONES I
Wall ConhactorNamo FROM TO DESCRIPTION -
4418-A 'IBSft. Si t't. Fro%.Ver 1S &Pl4
ft. ft. 1 1
NC Well Contractor Certification Number
Aqua Drill, Inc I&OUTER CASING(for muifl-eased Wells)O_R LINER(ifap able)
FROM I TO DIAIVIEFER THICKNESS. MATERIAL
Company Name Co ft. 55i R• 16aa io. `119. PvC
9 I MANNER CASING.OR TUBING(mo hernial dosed-loop)
2.Well Construction,Permit#: 3"11' N kig'-OO,4nC) FROM •TO ._ DIAMETER THICKNESS MATERIAL
List all applicable Well construction pants (l.e.UPC,County,State_Variance,etc.) It. ft. in.
3.Well Use(check well Used j it. ft, I; �.
Water Supply Well: - I - 17.SCREEN .
CUItUIHI FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL .
' DMunicipaVPublie ft. ft, fa.
Geothermal(Heating/Cooling Supply) K I Residential Water Supply(single)' R, ft. to.;
Industria//Commercial DResidential Water Supply(shared) .18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: el ft. a,3 R' ( emeriti- Pare A. wi cvc 1r;
Monitoring _ EtRecovery F ft. ft.
Injection Well:
Aquifer Recharge DGroundwaterRenlediation
Aquifer Storage and Recovery °Salinity Barrier 19.SAND/GRAVEL PACK(if aspittabtel
FROM TO MATERIAL' EMPLACEMENT METEOD
Aquifer Test ©IStomtwater Drainage ! ft. ft.
Experimental Technology OSubsidence ControlR ft'• ! ` I'
Geothermal(Closed Loop) OTracer
20.DRILLING.LOG(attach additional sheets If necessary)
Geothermal(Heating,/Cooling Retain) (Other(explain under#21 Remarks) FROM TO DESCRIWFLON(color,pudntm conhoeg twe.a„m the'de.)
I O ft. I I ft. Red' my-\ I Uo'
4.Date Well(s)Completed:4-tl'Olt-% Well MN . . 1.I L• 50 n• �g c.l< y Sawa at1
Sa.Well Location: 60. .ft. 55 ft. fr.Ceh.\ e
awn Vinaers Hems . I 55 " ci s ft• 6104\( t .
FacllitylOwnerName Facility ID#(If applicable) R. ft.
�t01�1.D©ck Ri A5 e 'D r. S't'o lees d�ie, l'_13S'I �' R. ;�1,.....a.�: ' �" '
Physical
6l)t Pseud nd2ip a-�4t., I� 21.REMARR$ I -.. - MA�( 0 Lo.2024 •
County
Forest IdcntlSttuitioa Noj(P1N) ii .,:.. h �➢
5b-Latitude and longitude in degrees/minutes/seconds or decimal degrees: ii:IV Cii 303
. Orwell field,one 1st/long is su&lcieat)
36014,A�•-is �r 22.CerNficatfon:
N to' 1' •%2.% W •
A .. 5.L.„...„.„_..... -c .-aHi
6.Is(ere):the well(s)alPermanent or DTemporary . I Signature ofCerti a.Well Contras I • Data
By signing this form,1 hereby tend that the wll(s)was(were)constructed In accordance
7.Is this a repair toan existing well: ®Yes or No with ISANCAC 02C.0100 or ISANC4C 02C.0100 Well Consaacrlo i Standen&and thata
If this is a irpaf,fill out known well construction information and'expiain the native oftlle eapyofthis record has been prodded to the'null owner.
repelwarder#21 remarks section or on the back ofthisform. I I .
23.Site diagtain 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"G11111 is needed. indicate TOTAL NUMBER.of wells construction details. You may also attach additional pages if necessary.
drilled: ++rr I SUBMITTAL INSTRUCTIONS I.
9.Total well depth below land surface: t4. • (ft)
For multiple wells list all depths(fd/#eren't(example•3(a)200'and?®teary 24a.For MI Wells:h winmit this font,within 30 days of completion of well
• 1 construction to the following:
10.Sta(ic.water level below topof easing: 5�t.
if water level Is aboveCasi„g.use ^ �� (ft.) Division of Water Resources,Information Processing Unit, -
A� 1617'MatlServlice Centetr,Raleigh,NC 27699-1617
11.Borehole diameters i. (Inn.)_ 24b.For Infection Wells: In addition'to sending the form to the address in.24a
12.Well construction method: fo :!i.�4 ft1 f j 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:
Division of Water Resources,Underground
FOR WATER SUPPLY WELLS ONLY: Injection Conlrol Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) IS 'Method of test: O M(.�'14, ►I 1•t 24c:For.Water-Supply&infection Wells: -In addition to sending the form to
type: Wilk 'lid 17 p ( ) above, alma subinit one � department o 3h dasou of
ty
136.D151nfeetion e• Amount: . ��d fj"j, com1 the a edttion of well construction to the countyhealy of th
"within(the county
where constructed.
FormOW-1 North Carolina Depanment Of Environmental Quality-Division-of Water Resources 1 Revised2-22-2016

GUILFO D COUNTY DEPARTMENT OP PUBLIC HEALTH
Division of Environmental Health, Water Quality Unit
400 W.Market St.,Suite 300, Greensboro,NC 27401
!i'seivr.4 of ConstPat1ct0®no Qepako or
Address of Well: 6e'� 'Dot,1� Ri�. Dr Abandonment ®�� ����`�9
elresa�le NCl351 IL/MUM6 ano,r.it Well Permit Number: .-1 - �� yj - d
Well Contractor Company: � � � LONGITUDE ��� ,' ��, . 3'` W
Completion Date: Li-r1•-at-j
Total Well Depth: �
was ft. Well Yield:_Ls_gpm Static Water Level: S®
Outer g Material: INC
Casing Diameter: bear in. Casing Depth: F'® ati®n Log
--�--ft. Depth Description
rimer Casing Material: From: Co ft. To: 11 ft. .. fir► I Clay
L.
Casing Diameter: From: _ft.To:.... . _ft. �acicv said. 6►e in. Casing Depth: ft. From: 5 ft.To• /�"�
GroutFrom:5 ft.To: 5 ft. _ cr n i-e
Depth From:_ft. To; ft.
1@llaterial Method From:`ft. To.
From:.ofg,'3'o:�3 ft. CemerA To:______ft.
From: O t.To: r a eut.k From• ft.To: ft.
From: ft. To: ft, - From:- ft.To: ft.
' From: f- t.To• ft.
Depth: 385 ft. ft.'Wate'WaterProd Production Zones
Yield: I gpm ft. ft. ft.
gpm gpm Pm —
m — gpm gpm
Method of Repair:
i j
Method of.Abandonment:
• I hereby certify that this well was constructed,repaired,or abandoned according to the
Rules in effect on this date and that a copy of this record has been provided to the well oowner. •
County Well
Well Contractor: j4
Certification#: 44l$ job
• � l `" Date: �
= _.. u-■TRr.
fdPJ3Y431 ttt,.:i.._�". z:.._ .�.'"A.7:x�La�xar:vmraa=,v� 6h; 4 3 .;S_ .k K ,T- M. _ _ :Record © Paej IInstaOBatlon
11
Pump Installation Company: , �J.. r - �_
Completion gate: l�l �j
Pump Depth: a®( � ft. Static Water Level: SC
Pump Brand: 1�w `
� ft.
f ®Sfl`-)L Pump Size and Rating:. hp 1 I hereby certify that this pump was installed and wellhead completed accordingto gpm
Rules in effect on this date and that a copy of this record has been provided to the Guilfordwe . County Well
the well owner.
Well Contractor* r�
d? Certification#: aim e.--Date:004/
•
Revised:January 9,2009