GW1-2021-02583_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Larry W. Ferguson �o'TM TZtM DESCRTPiTON
Well Contractor Name ft 20 ft
NCWC 2029-A h 70 ft
NC Well Contractor Certification Number M OUTER CASING or mtdti-coed wens OR LIlV$It bk
FROM TO DIAMETER TffiCHNFSS MATERIAL
Ferguson's Well and Pump, LLC o ft- Pc 2/
Company Name 16 1NNER G ORTUBING dused
q,, FROM TO DIAMETER THICKNESS MATERIAL
6 )
L Well Construction Permit M dA t ft� & m
List aU applicable well corsi ezon perncts(Le.County,State,Parlance,etc.)
tit ft is
3.Well Use(check well use): M SCREEN
Water Supply Well: FROM TO DIAMITER I SLOT SIZE ITEQCKNFSS I MATERIAL
❑Agricultural ❑Muni -pal/Public
ft ft in.
OGeothetmal(Heating/Cooling Supply) _ esidential Water Supply(single) ft. ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) M GROUT
FROM I TO MATERIAL EMPLAC aNT METHOD&AMOUNT
011rigation V tc 20 ft Concrete Gravity-Flow
Non water Supply Well:
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 1%SAND/GRAVEL PACK Of molicable)
ft.
TO MATERIAL Et1lPIaCEMFNT]►lEtHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft
❑Aquifer Test ❑Stormwater Drainage f ft
❑Experimental Technology ❑Subsidence Control
28.DRIIbIlVG 1,OG atfarh additional dock if
❑Geuthermal(Clust:d Loup) ❑' aora' WFRIOM TO DEscMPTZexv rotor hardn sd1/n k sac,ac
❑Geothermal(Hestia Return) ❑Other(explain under 421 Remarks) ft* it
ft. ft.4.Date Well(s)Completed / Well IDtt ft. ft �0
Sa.Well Location: fL
A h M
Foci ry" G /Owner Naltic Facility M#(if applicable) & M
h it ft
Physical Address,City,and Zip 21.REMARKS
l�i.tr,rt�,.,nh g7hI l G �t 34
CounT— Parcel Identification No.(PIN) p1 CjZI
5b.Latitude and Longitude in degreeslminutes/seconds or decimal degrees: 2L Certification:
(if well field,one ld4ong is sufficient)
3S°'efe;aa,my N S��°�/�S/� (oSSS � W vZ l
Signaturi of fied W ! nt ro
6.Is(are)the well(s): �_,Wc rent or ❑Temporary By signog thisfbnp�1 hereby certify that the weU(s)was(were)catstnkted in accordarwe
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well ConsnuctI x,Standards and that a
7.13 this a repair to an existing well: ❑Yea or o copy of dtis record has been provided to the well owner.
1f das is a repair,JUI out known well construction h omotion and explain due nature of dae
repair wider#21 rranarks section or on die back of d9s form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S Number of wens constructed: construction details. You mnv also attach additional pages if necessat)•.
For nnda le 6geetron or ease-water supply wells ONLY wish the same cros&uc*ort,you can
M&Mut arse form SUBAC'1TAL INSTUCTIONS
9.Total well depth below land surface: 710 (ft) 24a. For An Wells: Submit this form within 30 days of completion of well
For multiple wells lust all depds tfe ervw(exmnple-3®200'and 2@1000 construction to the following:
10.Static water level below top of easing: S4 (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service'Center,Ralei&,NC 27699-1617
11.Borehok diameter. 10 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rotary above, also subunit a copy of this film within 30 days of completion of well
1L Well construction method: construction to the following:
(i.c.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16M Mall Service'Center,Raleigh,NC 27699-16M
Blowing-Rig24e.For Water Suprift&Injeetion Wells: I i addition to sending the form to
13a Yield Win) Method of teat: the addresses) above; also submit one copy of this form within 30 days of
136 DiaIDteetion type: Chlorine A,hhount )Z. completion of well constructioni to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013