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Home My WebLink AboutGW1--06383_Well Construction - GW1_20231002 . . i 1 Ty aiLaAa.1%....a.r.i.‘I,a LW I.....L XVI.•.1%.F.OL...1UITULN For Internal Use ONLY: , This form can be used for single or multiple wells • . . 1.Well Contractor Information: • • • I . . .,. . . . . . • Bobby W. Potts • - 14.WATFRZONES;• • - • 1-1 . FROM . TO ... ,, DESCRIPTION . Well Contractor Name . ' ft 500 ft - . . NCVVC 2028-A ... . - _ :ft. . .ft. - I 1 . ' . • . • • . . . . NC Well Contractor Certification Number • LS 01:ITER CASING(for mnifircasedirells)ORLINER Of avOcable) • _ ' • • . -FROM • TO • DIAMETER THICKNESS MATERIAL Ferguson's Well-and Pump,.L.LC •- . , • ft. _•V ft' tr eX15 In'. VP/AS.0r SW Z/, • . Company Name • , . . . 16.0_WR case*OR TUVING.hmidsermsd• a-(oo) . ' " . •FROM ' TO ' • ' ,DIAMETER THICKNESS 'MATERIAL 2.Wen Construction Perinit/4: ' .2-112 at too- tqc 1, . ft. • . ft - I: in. • List all applicable well construction pennits(1.e.Counly,State,Varianc4 etc.). . ,• I. ft. ft I': 'in- , • 3.Well Use(cheek well use): . . ' , 17.SCREEN .. . • . Water Supply Well: . ..- . . . • • . - . FROM' TO DIAMETER. SLOT SIZE THICKNESS MATERIAL • .• • • ' in. . DAgricnitural • ' 02icilial/Public ft ft . ft •ft. iM• . OGeothermal(Heating/Cooling Supply) 1 midential Water Supply(single) . , • , Oindustrial/Commercial DResidential Water Supply(shared) FROM TO°13T. Ta : .. _ . . MATERIAL EMPLACENTENTMEMOD Si AMOUNT Divination .. a ft 20 . ft Concrete Gravity-Flow . Non-Water$UpplyWell:'• ' • • - ' • ft : . , ,.ft , . OMOnitoring 'Oitecovery Injection Well: ft.. ft. , • . ' . . ClAquifer Recharge . Clarormdwater Reanediation . 19.SAND/GRAVEL PACK(ifiutilicalde) • . T . • EMPLACEMENT METHOD . ' . ClAquifer Sterage and Recovery CISalinity Barrier FROM O MATERIAL.. 'ft. fi,' .. ClAquifer Test • ' -CI Stomnviter Drainage ' • . . ,. ft ft 1: ' ClExperimental Technology OSubsidence Control • 11 , - . . •...., t • •20.DRILLING LOG(ittach addititind sheets ffneastary) - . . OCreuthermal(Closed Loop) OTratier .FROM TO DESCRIPTION(color,hardness,soWroc.lt type,grain sl2e,etc.) OGeothermal(Heating/Cooling Return) IJOther(explain under#21 Remarks) 'c) ft' 65. •ft. ' .C lay . . 4.Date Well(s)Completed 7 0 j ,Well RV . /5' f". ZS ,• ' ' • ..Calei r/-erle-e, . AS"' 3 " . • • ile• rail< - Sa.Well.Location: , , • •7ps • , 0 rifimi,t 7(c e bi iffh Ail ifdl&v.<r'c ittliDa4 bk. 1-11.1/11'1 i in rd...... ' ft.. • ft. . , .. • . Facility/0;mm Name .„ Facility Wit(irapplicable) ft.. . . . - ft . . • 3,13 e:PkIks Zwe bri'oe .1.-len-iersoin-/d/e_ . - f, . f, Physical Addict's,City,and Zip `.' • • f' . . „ 2L REMARKS • Ile.ri,,I.i-, e is.) - . . . 01.000g-7. 6_7811 - - ' ' OCT e 9 2023 County Parcel Identification No.(PIN) • .. • . , 51:.Latitude and Longitude in degrees/minutes/seconds:or deebnal degrees: • • . . . D',IV 017,10G (if well field,one lat/long is sufficient) 22.Certification. Signature 44e,‘6e; . .. . of Ccrlifiell/ • "Con r 1, , • 6.Is(are)the wake): ornament or OTemporary • By..signing this form I hereby certify that the well(s)'was(were)constructed in accordance , ' k with LaNCAC 02C.0100 or 15A NCAC 02C.0200 Well Constr.:lc:noir Standards and that a 7.Is this a repair to an existing well: ' ClYes Or do - copy of this record has.been pro;i d e d to the well owner. If this IS a rePalr,fill out known well construction information and explain the nature of the - • • • 1, • repair under#21 nunark:s Section or on the back of this foam - 23.Site diagram or additionalwell details: • • . j 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 Weaker or non-water supply wells ONLY with the SONIC canstrudion,you can i • submit Oneforrn SUBMITTAL INSTUCTIONS. . .. . . . . . 9.Total well depth below land surface: • jp5 . (ft.) 24a. For All Wells: Submit this:,- form within 30 days of completion of well • .For multiple wells list all depths rdeerent(exampk- 0 'and 2(0,100) ' construction to the following: 1, ,. • , 1 , 10.Static water level below top of casing: . btO (ft) Division of Water Quality,Information Processing Unit, rWaler level is abas4 casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 1 i 11.Borehole.diameter: :i.,... • 6 (in.) 24b.)For Injection Was: In addition to sending the form to the address in 24a above, also submit a.copy of this.fOrm within 30 days of completion of well . 12.Well construction meth .method: Rotary •• • , . . • construction to the following: (i.e..auger,rotary,cable;direct push,etc.) • I , • . •• Division of Water,Quality,Underground Injecdoo Control Prpgram, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 I, .1 Blowing-Rig 24c.For Water Szninlv&Infection Wells:.In addition to sending the form to 13a.Yield(sim) ••I• •' Method of test: the address(es)-above, also submit:one copy of this form within• 30 days of • Chlorine' ;Lib.Disinfection type: . , . Arooroit. .' OZ. . 'completion of well construction to the.county health department of the county • • • where constructed. I ' . .. . Form C-W-1 • North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013 , I - I