GW1--04469_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information;
Gary Thompson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4418-A f00 it. IOS ft. f(p,c t:r� CO ( ?M
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased hells)OR LINER(if ap lieable)
Aqua Drill, Inc. FROM TO DIAMETER ' THICKNESS MATERIAL
0 ft. go ft. V i I.1 in. SDR 3A\ Pv C
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3,4 -OQ-i..)N %R-0O5' c t FROM TO DIAMETER THICKNESS MATERIAL
it. ft. in.
List all applicable well construction permits(i.e.UiC.County.State, Variance.etc.)
ft. ft. in.
3.Well Use(check well use):
17.Supply Well: SCREEN
Water Su
pp FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in. '
Geothermal(Heating/Cooling Supply) CS3Rcsidential Water Supply(single) ft. ft. in. L
Industrial/Commercial DRcsidential Water Supply(shared) 19.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 30 ft. Con(,ie Af PcNiea {1fs`t"t -kCvC
Monitonng 0 Recovery ft. ft.
injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) DI racer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness.soiVrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 ft. '1 ft. A p
ecC Idol
4.Date Well(s)Completed: 1-\Qa._D.4 Well lD# , ft. CBS fL sancirn'f l�
5a.Well Location: 86 ft. Cl0 ft. ilJe li/'n`n\ve
i LANtnrlay vl\ctecs Q 10 ft 165 ft RI0-e tt'Ariat
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
ft. ft.
10 14 iltn►pQ)e TRIO\ 6(eeccrb0co NC a1455 ft. ft.
Physical Address,City,and Zip
S U'1FOLa 21.REMARKS
County Parcel Identification No.(PIN) JUL 3 0 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field.one iaUlong is sufficient) 22.Certification: ..,rrA'^: a--� _ I
MI
.,
6.Is(are)the wells)iiI II Permanent or OITemporary Signature of Hilted well Contra or Date
By signing thin fait,i hereby cer:iJi'that the well(s)was(were)conctnicied in accordance
7.Is this a repair to an existing well: f Yes or ItNo with i5A NCAC 02C.0i00 or 15A NCAC 02C 0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 021 remarks section or on the hack of this form.
23.Site diagram or additional well details:
R.For GeoprobelDPT 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-I is needed- Indicate TOTAL NUMBER of wells
drilled: — t e SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 165 (ff•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiferent(example-3@200'and 2(a(100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: QO1►GA(1 P1/4t e construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) sc) Method of test: NA,kCY14'1 one 24c.For Water Supply& injection 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: 41V\ 10°e6 Amount: 1 b OZ 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 Revised 2-22-2016

GU LFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W. Market St., Suite 300, Greensboro, NC 27401
Reciv l of Constructrara, Qepaor>'o Or Abandonment gent of a Wail
o
Address of Well: 78 a W it Cp p 1 t .Ts o•l j, 6-ree nsboco N a1-1S5 L A '1'mm 3 6° I % 49 ...t
Well Permit Number: a4-C a- .w N Ng- 00 5 VI LO IGITMt -7 9° ,Hi* LI I , 3"
Well Contractor Company: AcL vo, Or,1 i, VI c Completion Date: "1-1`a -a 4
Total Well Depth: 65 ft. Well Yield: 50 gpm Static Water Level: t--10 ft.
Outer Casing Material: PVC SOP a 1 Formation Log
Casing Diameter: 6114 in. Casing Depth: 90 ft. Depth rtescription
From: 0 ft. To: `l ft. et d (loot
inner Casing Material: From: -1 ft. To:S5S ft. Sound cock
Casing Diameter: in. Casing Depth: ft. From: BS ft. To: 9 0 ft. 31.'e (F ca 6 n- k
From:9 0 ft, To: 1 bS ft. R 1 or (coin.,i e
Grout From: ft. To: ft.
Depth Material Method From: ft. To: ft
From: C) ft. To: O ft. C ur u i c i c Pouted f'ror+ A r vc k]From• ft.To; ft.
From: ft.To: ft. _! From: ft.To: ft.
From: ft. To: ft. From: ft. To: ft.
Water Water Production Zottn' .
Depth: )OC ft. ft. ft, ft. ft. ft. ft.
Yield: SC gpm gpm gpm � gpm gpm gpm gpm
Method of Repair:
Method 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 of this record has been provided to the well owner.
Well Contractor: A.A.,./ -'
Certification#: 9 iI'18-Pt Date: I-➢8-3 9
Word ©f Pump linota00a4 0®n
Pump Installation Company: War,'a n L Completion Date: 07/?ye y
Pump Dep tt
20 ft. Static Water Level: 90 ft.
Pump Brand: ow i 5e Size and Rating: 3
/
Pump hp /O gpm
I hereby certify that this pump was installed and wellhead completed 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.
Well Contractor: �
_ .t__v_._ Certification #: ,g 7j2C Date: 07/25 2y
Revised:January 1,2009