GW1--06782_Well Construction - GW1_20241114

WELL CONSTRUCTION RECORD (GIN-1) For Internal Use Only:
1.Well Contractor Information: 1
David Belcher 14.WATER ZONES j ;
Well Contractor Name FROM TO DESCRIPTION
4594-A 6'98 ft• 5lN fL lt��ai?k( re:faijre)
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi cased wells)OR LINER(if ap licable).
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
x ft. ft. 9 in. •v i• .�
Company Name W iw�. [5 ��° (IV
�p 16.INNER CASING OR TUBING(geothermal closed-loop),
2.Well Construction Permit#: tP"I•-Ott. il)(t))'a-on 590 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable u•ell construction permits(i.e.U/C.County.State,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft. it. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0 unicipal/Public fL ft. in.
Geothermal(Hcating/Cooling Supply) iesidential Water Supply(single) ft• ft. in.
Industrial/Commercial DRcsidcntial Water Supply(shared) 18.GROUT •
irrigation FROM TO MATERIAL Rite
METHOD&AMOUNT_
Non-Water Supply Well: jai ft. ,,,nt i ft• 6Pl,le+:)� i"&e"zoif 1 f Bur
Monitoring DRccovcry ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19..SAND/GRAVEL PACK(if applicable)
• P Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD •
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary) '
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
C) ft. ter® ft. ant
4.Date Well(s)Completed: ►i 'Sr•07�l Well ID# 'Vi)0 ft. 4ci ft. VI c Fil e/ SSt2
5a.Well Location: lie ft. 55 ft. e ii ie Ci(44^l(1'ge
gret°Itvl 1�;r<der-, 55 ft. (�,25 ft' dtif.4e CY'fral e
p�j Facility/OwncrName y� Facility iD#(if applicable) ft. ft. _
60i,711) =�:�,_.t5 geje,'I- 9,ily (? 11il. Sit't"alrre�1^ I� srit��. ,42�7. 0 ft. ft. b .a,.4 .ds
Physical Address,City,and Zip ft. ft. N(1 V 1 / 2024
C iL9ji,�t74 C) 21.REMARKS ` l'
County Parcel Identification No.(PIN) IR`:;::+,,,.��•] �'-'",:',<;;: t.??tt
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) 22.Certification:
rr�� `fit
.i+O°Ill nl3.0 N Od ►. r 5,.a7 u W
ri...,i 1.1.- ,--- ti•12-aLi
6.Is(are)the well(s)f ermanent or Temporary Signature of Certified ell Contractor Date
By signing this form,I hereby certh•that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or Iltl<lo with iSA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out known well construction iabrmation and explain the nature oldie copy of thisrecord has been provided to the well owner.
repair under#2/remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprohe/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 I 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 surface: (9-IF7 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiferent(example-3f200'and 2Qa I00') construction to the following: ,
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
!flouter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (0 (in.) 24b.For Infection Wells: in addition to sending the form to the address in 24a
p above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Apr('t t^tgr /Att,0' construction to the following:
(i.e,auger,rotary,cable,direct push,etc.) (f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0Method of test: efikh 4 nie 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: 117H7oc94 Amount: ig2c>" completion of well construction to the county health department of the county
where constructed. )
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourcesi Revised 2-22-201 6

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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 274011
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Record of Construction, Repair, or Abandonment of a Well
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Address of Well: 5 Pv jer4:9.D A;�fe h s _c t.tI , AJC,7715V LATITUDE 3 JLJ ,.3 . 0
Well Permit Number: .N.01.1. tot..1)4p,a cr9S90 LONGITUDE 4j-0 1 .V9 . .:77
• Well Contractor Company: it oua ';;it Me. Completion Date: II•Vs at,
Total Well Depth:.626 . ft. Well Yield: iO gpm Static Water Level: 6_;0 ft.
Outer Casing Material: Pi/c ' Formation Log
Casing Diameter: a..25 in. Casing Depth: 65 ft. Depth Description
From: `D ft. To: 2C),ft. _
Inner Casing Material: From: gn ft.To: Lt ' ft.• r . 1.
Casing Diameter: in. Casing Depth: ft. From: iV ft. To:, 515 ft. ''. ar .
From: 55 ft. To:c.25 ft. (Niue Co- Vie
Grout From: ft. To: I ft.
Depth Material Method P From: ft.To: I ft.
From: Q3 ft.To: Ali ft. (.e a$ 16.to►h MuctiFrom: ft. To: ' ft.
From: ft.To: ft. - From: ft. To: i 'ft.
From: ft. To: ft. From: ft.To: I ft.
Water Production Zones
Depth: ,590 ft. ft. ft. ft. ft. ' ft. ft.
Yield: a0 gpm gpm gpm gpm gpm gpm gpm
Method of Repair:
Method of Abandonment:
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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: 22: )`13g jg, Certification#: 4594-A Date: 1(•1,9• W
R cord of Pump Installation .
Pump Installation Company: ¢tea jh'// fir Completion Date: /1//7/Z y
Pump Depth: ZOO ft. Static Water Level: bj o i : ft. /
Pump Brand: /oc�Jsse Pump Size and Rating:' 3PPI hp /0 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 will owner.
Well Contractor: G1A"/ 9j � Certification#: z677- C Date: V /V 2 y
Revised:January 1,2009
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