GW1--06231_Well Construction - GW1_20241021

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
David Belcher 14.WATERZONES _
Well Contractor Name FROM TO DESCRIPTION
4594-A 60 f t' ?traLi r`' i ii GPM e r,Auci
NC Well Contractor Certification Number 9 ft ci1Oy R )5 6P.R(F flaC4f 02-�)
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name :/ c� II ft. 90 ft. 6• r5 in. ' 00:
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ,04-ark'[�;`)VR-COCA& 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
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0 i unicipal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) ij!Residential Water Supply(single) ft. ft. in.
Qlndustrial/Commercial DRcsidcntial Water Supply(shared) 1&GROUT
(Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. 0 ft. (644404.
Voir 443;t'1 ►art trA
QMonitoring DRecovcry ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
®I 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) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
®Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness:soNrock type Amin size etc.)
Q ft. 90 ft. /'1y DD
4.Date Well(s)Completed: i b '7., l'i Well ID# rv(' ft. �5 r' ft' C 1��('I SrJ[)�!r fie)
5a.Well Location: /St`j n' ,O ft' Wei, Son �i irr
l:iy1 icdptl, C(�nn c1L�` ICi0 ft. 776 ft. !more � 1
Facility/Owner Name Facility ID#(if applicable) ?�� ft. 3; ft. ' f fte l C crrQt)ite
4101 !c',_. 4 Mist(?ii i illvenue f (C(•✓erlatbi(n/(l;�',p1l10 ft. ft. �1
Physical Address,City,and Zip Ir ft. ft.
i 1.61 i(:'C'l _ 21.REMARKS .. • '
s
_ C .it. / 4,.,t6....-
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' D 7 A
(if well field,r one
lat/longlay is sufficient) ,gyp p r 22.Certification: if I,, J 1 u r
_i�etC 5' At"5.711 N /90 5It -94. j'I W :7 rr rvc: !?
9 It„J.i i,.,l. ., �
6.Is(are)the wells) ermanent or ijTemporary Signature of Certified Well Contractor Date
By signing this form,i hereby cerifi,that the well(s)was(were)constructed in accordance
7-Is this a repair to an existing well: ®Yes or Wo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Canstnrction 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#21 remarks section or on 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-1 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 surface: 395 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2(0100') construction to the following:
10.Static water level below top of casing: - 30 - (ft.) Division of Water Resources,information Processing Unit,
!fuzzier level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: I,{s (in.) 24b.For Injection 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: P,061 44- 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: Tole
Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: Lind .1iille 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: H1'H .0 e/6 Amount: 1(007 completion of well construction to the'county health department of the county
where constructed. I
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016

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GUILFORD CIUNTY DEP_.l'TltliEM'•F PUBLIC HEALTH
'Division of Environmental Health,Water Quality Unit
400 W.Market St.a Suite 3OO Greensboro,NC 27'1,1
1{ of ° 'pp AA
Address of Well: 1
Well]Perraait Number: , ?Li-a7-to 1 A JH -0906 LONG �_ L... _cam... A.__
Well Cacii Lettor Company: 410, 1)61 1 _Inc Completion Date: /OO•7.,.94
Total Well Depth: j?i_ ft. Well Yield: '3O gpm Static 1 ater Level: ft.
®hater C ag Material: ' Fero/eon ding
Casing Diameter: 6. .a.4 in. Casing Depth: 70 ft. Depth Description
From: 0 ft.To: -20 ft - tiles
linneE Canting Material:
From: ek ft.To: AO ft. J. .
Casing !Diameter: in. Casing Devi: ft. From: 50 ft.To: ecn ft.
From: (0 0._ft.To: %it. C '
Grant ant Fro n:1f ft.To: 245 ft. 'ir/r1 6rnr
Depth Material Method From: ft.To: ft.
From: O. _ft.To: Al it. 66) 4 Prie r V aric From: ft.To: it.
From: it To: ft. - From: ft.To: ft.
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From: ft.To: ft, From: ft.To: ft...
W...tf r Prsit elfl©n Zoom
Depth: kg_fi. _2C2.0 ft. #t ft. ft. t. ft.
Yield: 1 5__gpm I.5 gpm gpm gpm _gpm _,®gam
Method of Repair:
1
Method of Abaudonment:
H heathy cell-*.i y that this well was constructed,repaired,or abandoned according to the Guilford County Well
klul-,Z iaa ect n•this date and that a copy of this record has been provided to the well owner.
Well Contractor:_Slyt ..9L tsd2.1.49,ir Certification 4: i-1571.1.A , Date: t •IO•2Ll
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.p7�j�`.. _�_0:>rc oyes]-�: r ;;.c1J katIL:Soj:a}.:t .�C3s1 .'y7lo.�iiY- - sr--
®f Pump Eut ;111atir n .
Pump Installation Company: +ad N The 1 Completion Nate: iol al z N
Pump Depth: Z 5 Z_ ft. Static Water Level: LIO ft.
Pump Brand: 67rr4n c+Po s POT Size;mod fling: hp 35 gpm
'hereby c ?tifi that this p-trap cuv.,• installed;Id 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 Conth :tor:, 7 €ve-1-. Colin' ae on 0:2 C 77- C Date: t 0/ r./2 ai
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Plastid:lar,ar S,OM .