GW1--04451_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: — — -
I.Well Contractor Information:
Gary Thompson
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
•
4418-A a4O 1t• Q,4 S ft. (t-0,, 40c IS 6Pfr
NC Well Contractor Certification Number avr7Oft. 9.taS ft. cfAC j`,I vs G
Aqua Drill, Inc. 15.OUTER CASING(for multi-eased7wells)OR LINER(if ap 'Ratite)
FROM TO DIAMETER <THIlC�KNN�ESS MATERIAL
Company Name 0 ft. I !as ft. I6174 in. JQR?` PVL
u jp 16.INNER CASING OR TUBING(.eothermal closed-loop)
2.Well Construction Permit#: 1 .0 S-b..1 L)f l C- 00635 I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County.State.Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
Agricultural �MunicipaUPublic Hum TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in. I
Geothermal(Hcating/Cooling Supply) LJ Supply Residential Water Supply(single) tr J
ft. I ft. .
industrial/Commercial Residential Water Su I J(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
Monitoring Recovery ft. 36 ft. Conct.,e►e Pok(ea-Croon krl1Ck
ft. ft.
injection Well:
Aquifer Recharge OGroundwater Remediation ft. ft.
Aquifer Storage and Recove 19.SAND/GRAVEL PACK(if applicable)
ry DSalinity Barrier FROM TO MATERIAL.
Aquifer Test EMPLACEMENT mutton
�S[onnwater Drainage ft. rt.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Ilcating/Cooling Return) Other(explain under#21 Remarks)
FROM TO DFscnn�Tum(color,hardness,soil/rocktype,grain size.etc.)
® ft. -7 ti
ft. f .
-1� t C lad
4.Date Well(s)Completed: 1-!CI"ail Well iD# -0-1 ft. i'1 o ft.
SC&Clafoc k<
5a.Well Location: 1 ao ft. 1 ae ft. g
J C 1 0 t Gf-an }e
Ikoas'$wood Homes 1, 5 ft. aas ft. 8! v e
Gfantir
Facility/Owner Name Facility lD#(if applicable) ft. Pt.
189$ VI (standee Cl" Gseensboco NC 21ySS ft. ft.
Physical Address.City,and Zip ft. ft.
Gut!Coc Q) 21.REMARKS ('1 r
3 U , t .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I •
r Y'
Ifr�G:t:.i.i:^.,l
(if well field.one lavlong is sufficient) ©f(1, �1.V
22.Certification:
36° a31 la. 6'' N 1q°46'S13e3" W, tyJl .1A
6.Is(are)the well(s)'t�iPermanent or Temporary gnature ofCe ' e ell Contrac • Date
By signing this/hrnt,I hereby certi(i'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or NNo with iSA NCAC 02C"non or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill met known well canal-tailor,information and explain the nature oldie copy of this record has been provided in the well owner
repair under#2/remarks section or on the hurl of ibis form.
23.Site diagram or additional well details:
S.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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
^
285p� SUBMITTAL INSTRUCTIONS u
9.Total well depth below land surface:
For multiple wells list all depths iidii different(example-30,200'and 2(a)l00') ons c
(at) For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: yQ (ft.)
If water level is above casing,use"+' Division of Water Resources,information Processing Unit,
{{ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.)
pO 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: i\p{��ro f 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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(pm) 3 G Method of test: CAiGh t iirAc 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
13b.Disinfection type: f11 1-11 O0% Amount: lb vz- completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources -

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health, Water Quality Unit
400 W. Market St., Suite 300, Greensboro, NC 27401
Record of C onstructgoo Q©peep or AbandonmentAddress of Well: I) N..1 bar+der Cr
(;re sbcr0 NC, 1"1 L155 L 6,T1'tutdE 3 t% 13' 1(„
Well Permit Number. a - S- N e 6
W Hit
Well Contractor Company: �C�ua p r:11 !n c LONGITUDE �'�, t{6� Spa 3•�
Total Well Depth: Completion Date: -1 - I°I - a y
P _ILL_ft. Well Yield:a___gpm Static ViTater Level: y fj
®inter Ca h PY
Material: C SDR a� -- ft.
Casing Diameter: Ca
sing sing Depth: 1 a5 ors ation Logft• Depth
hazer Description
From: 0(�ul:g Material: ft. l'o: l ft.
R e c u a_
Casing Diameter: in. using the From:? ft. To: aoo ft. $ar,drec k
Dep —�`ft. From:iL( eft. To:�, 5ft. B I�u< 6-rain ore
Grout From: tas ft. To:at ft. gl1cALeL��e
Depth Material From: ft. To:`__ft.
Method From:
------
From:�_ft. To: eft. 'oncre ie eo,;ica cC,x►{ruckF ft To:_ ft.
ft. To: om: ft. To: r ft.
ft.
ft. To: ft. .--. From: ft. To: __ft.
From:
From: ft To:___ft.
Depth: ot'�O ft. agpWater Production Zones
Yield: �gpm �ft.m —_..� —
ft. - ft. ��_ ft ft. ft.
gpm gpm ---
gpm gpm gpm
Method of Repair.
Method of Ab andonment: — --
---:
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.
We11 Contractor:
_. Certification#: _uy l $-A
�7., Date: - l � -
ZL
(I corn 0 Pump EnstaQpat can
Pump Installation Company: fW/
Completion Date: 7 y
Pump Dep ; /,,,ro ft. Static Water level:
:rand:� �w,, -----�__.---ft.
Pump
Pump Size and Rating: ih=hp I hereby certify that this pump was installed and wellhead completed according to the Guilford gpm
Rules in effect on t ' d and that a co ford County Well
y of this record has been provided to the well owner.
Well Contractor: 2
._ Certification #: ? y
�..._. ..Date: 0%?:4 a
Revised:January 1,2009