GW1--04316_Well Construction - GW1_20230626

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells .
1.Well Contractor Information: -
Bobby W. Potts 1A..91!4TER2 iEs.:
PROM TO DESCRIPTION
Well Contactor Name ft. /rf1 ft _
•
NCWC 2028-A ft. ( D ft ,
NC Well Contactor Certification Number , " 15:OUTER MEVOiformnlfi:cfsed.wells)OR LINER Of )
Ferguson's Well and Pump, LLC ft PR°M TO 'DIAMETER THICKNESS MATERIAL _
0 l 6015 Z/(WAY fac S J72Z/
Company Name . '16.INNER CASING ORTUBING:(geothermal dnted4oUp). -
^ // PROM TO DL5METFR THICKNESS MATERIAL
Olt 2.Well Construction Permit#: el a . ." 6 0 (a li ft ft in.
List all applicable well cwtstructton pen nits(Le.Comity,State,Variance,etc.). •
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ft ft. in.
❑Muni ' blic
OGeothermal(Heating/Cooling Supply) Supply(single)
ft ft in.
(Hestia Coolin Su 1 esrdential Water
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT:.. :. _ .
FROM To MATERIAL • EMPLICEMENTMETHOD s.AMOUNT
❑Irrigation ft. 20 ft. Concrete Gravi Flow
Non-Water Supply Well: 0 {�_
OMonitoring ❑RecoverY ft it
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation• '19..SAND/GRAVEL PACK t3fap sable) ' .. . -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft: -
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology 0 Subsidence Control t,
.20:DRILLING"LOG:(aitaelvadditiiinal sheetiftneeessmy)
❑Geothermal(Closed Loop) • OTracer • PROM TO DEStR WrIoN(color,hardness,soil/rock typs,grain she,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2l Remarks) d ft to .ft /t lay` .
c n�, ft ft l ( �/ �,( �Q
4.Date Well(s)Completed: S ?i /)Well ID# • ��n 60
ft ca y N S/fit-c
5a.Well Location: •
Al j)fn�r 1 (.S o$ wolf/tow6% �'!p ft. �Ur�ft a UJiL}�
ft ft
Facility/66er Name Facility ID#(if applicable) 'r-�'T- r;' r ss"
- ft ft I `-,r y I t"" 0
I D. -rot/„a j ap..y agd9:.4 ILPAupnoact -• -) ft ft , ,
Physical Address,City,and Zip 1zEM S I t Q. �q
•
utnC6in19•C - t1 LI3os 'I La int.wir.tdian ;Pic !.z4:1 l;r.E
county ' Parcel Identification No.(PIN) LNIQi8OG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce lion:
(if well field,one 1at/long is sufficient) .
j S®Y3 D0113?g'�'//N S A('')V e 7173D%•,w 4. _
,��� ..;&
Ste of cd Well Contractor
6.Is(are)the well(s): , ermanent or ❑Temporary
By signing this form I hereby certify that the weA(s)"vas(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or o copy of this record has been provickd to the well owner.
If this is a repair,fill out known well construction information cord explain the nature of the
repair under#21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary. •
For multiple iryectton or non-water supply wells ONLY with the same construction,you can - ---
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: • b.S • (fr.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depthsif'drfferent(example-3(Q200'and 2@100') construction to the following:
10.Static water level below top of casing: AD (ft) Division of Water Quality,Information Processing Unit,
If water level fs above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: :i. (a (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rota above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
- Division of Water Quality,Underground InjectiorkControl Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: Blowing-Rig 24c.For Water Swish&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: Chlorine Amount• !' OZ. completion of well construction to the county health department of the county
v where constructed.
Form C•W-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013