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Home My WebLink AboutGW1--06464_Well Construction - GW1_20231002 1 .• WELL CONSTRUCTION RECORD For Internal Use ONLY: •This font:ein be used foiiingle ormultiple wells • . • • . .1.Well Centimeter btformation: , ! • : . -. . • •Bobby.W. Potts 14.WATERIONES. • , I I PROM TO . , DESCRIPTION • • . • • • ' • • Wen ConbactorNamc ' ' " 5.10 "• 1 : ' . . . . . , . . _ . • : NCWC 2028-A ft' s 70. ft. . .• . . . . • . .• • . . . . • IS.OUTERCASING(fur Madti•essid Wells" . . )ORLINER" Of ) • • NC Well Connector CatifteationNumber • .. FROM TO DIAMETER THICENFSS •MATERIAL . .. ' . Ferguson's Well and Pump, LLC 0 fu 72. .a. 6 (. •:.51e• 2 (6-(IAS" . . . . . . . ... -Cam • .pany Name • 16.INNER CASING ORTURING enothernial deo:44000•• : .:. . . A....." ..., ..7 , FROM TO- DIAMETER . THICKNESS' MATERIAL • • . L Well.Constauction Perinit ti:' • 0.`1 h.- a . . . ft • . ft.. • '' ' In. . !,. • . - Lis tall applicable well construetion permits(1.e.County StataVariance,etc.) . ,7 ft. . fe. • ; :3.Well Use(check well use)t • . .• Water Supply Welk . . . PROM TO • DIAMETER SLOT SIZE THICKNISS MATERIAL :• . . - ft ft. il?, . ClAgrictiltural 1:3ialial/Public , • ' . . EL ft• . . • ,. ['Geothermal(Heating/Cooling Supply) 0' •:,..deritial Water Supply(single) ft • Mgdu,s011140Diaercial " • CiReOclential Water SuPSY(shared) . moll m PUT TO '•' MA TERIAL • MEI:AC/ME:NT METHOD&AMOUNT ' • Mtrigation •: - . . . Non-Water Supply Well 0.: ft' 20 ft', Concrete Gravity-Flow ft ft. • . . : • • , . ' °Monitoring . CIRetiwely Injection Walk ft. ft . I. , . . . . . : .°Aquifer Recharge . ClGroimdWater.Remcdiation 19.SAND/GRA VIM PACK(if am di CI aid el - . .. : - FROM. TO •' 'MATERIAL a . EMPLACEMENTMETHOD • °Aquifer Storage and Recovery • OSalinity Barrier I... ' ft. ft: •['Aquifer Test CIStomtwater ft. - 'Drainage " .• ft- :i . .. . . OExperimentitl Technology • thSubsidenCe Control . . ..• . ri: .2o.DR1LTING LOG.(attach additineal sheets ffnecessessil - - • - . • 'OGeuthMnitif(Closed Loop') ' ' • OlTracur ' • PROM. TO . DESORPTION(calor.haidurs.WM&in*.min she,eto • °Geothermal dieattiignotAing Return) . °Other(explain under#21 Re:Marks) e2 ft• . (5 .11- Cl.(.tv . . . igi... irS. ft' 4.Date Well(s)Compieted: 'A. •Well MN AO ft.. l) •ft.- Sa.Well Licidlon: • 7A.-ft• ep«s ft. : .. ',6..M.(At iti-it• Aktrie tc; I oo fe • ft. . ft.- . (v . Faellity/Oweet Name . • Facilitylidi(if applicable). ' . ft. . • ft. • • • • ---.:-"'•. ;'-'ii) ,f 7.,:n 1.‘kel 6 Flia-1 13frcineh(2-el • rb Arj/ii.4 i I Q1375.3 ft. ft 1:1::: •-•:--',L. e 1..... '''1" •"'''* . , 1„.A.-. •••••• Physical Address,City, Zip 2L REMARKS O , 9 0Z3 r\Oi i'66.1.e" . . . . ...GI-MSc(to Lihrto • . .• oCI 0 - •1 County Parcel Identifitadon No.(PIN) " I ..,,,."•ung-ti'`1 ....•,..r.:•jc . . . • Sb.Latitude and Longitude in 44reeshninutes/seeonds Or decimal degrees: 22.Certification: • •. awl:4113dd,one latilong is sttftitient) i 3s6.c3tO34,q7,21/ N TA 83.(/ '-$1.-C3Fogil W . 17a./6,12, lit g7-f; . 4/7742.2._ • Signature of,ged'Fell Contran r i ' 'tac .• 6.Is(are)the well(s): ermanent or OTentporary By signingdzis form,I heieby.CeniP.Smiths well(s)was(were)' ecnsintited h:aCconiance. • • • with ISA NCAC 02C.0.100 or 154 NCAC 02C.0200 WeliConstructionlltancisrds and that a 7.Is this a repair to an existing Welk.' ['Yea er iii?,76-.7*. copy o f this re•cord has been provided toll*well invnen- I:. It'd&is a rePair,fill out lotawn well conitnictioninforinolion and explain the mew tit& repair wider 021 rowan:ea=or the back ethisforns 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 wells consftneted: . • / • . • • . . construction details.,You may alseattach additional pages if necessary. • For*add*Itgection Ornon-Water supply wells ONLY with thee ante construction,you con •• • • ' • • • I ' submit one fonn SUBMITTAL DisrucrioNs l' • 9.Total well dipth belovi.1i:inlaidkm • (ft.) 24e. For All Wells: Submit Ihis form within 30 days of completion of well • For mg411*!WI s Aft all dePdOlfefrffe0#(àwnple 3.(440'and21g100) construction to the following: ' • 10.Stitic water level below top of casing: ,2,,00 .4 CI) Divigion.of Water Quallti,Information Processing Unit, rwater kvel is above casing.use"+" 1617 Mall.fiesvire CIenter,Raleigh,NC 27699-1617 . ' 11.Borehole diameter '••• 4 (in.) 24b.For Iniertlon Wells: In addition to sending the form to the address in 24a • • : • ! • above, also submit a copy of thi fOrm within 30 days.of completion of well • • . 12.Well construction method: Rotary . construction to the folloning: ... (i.e.auger,rotary.Cable direct push,etc.) • Division of Wilier Quality,Underground Injection Control Program, • . FOR WATER SUPPLY WELLS ONLY: • 1636 Mill Service eesiter,Raleigh,NC 27699-1636 13i.Yield(gpni) M d ' Blowing-Rig. 2Ae.For*mar Sur&&Inieeti o.n1 "Fi elis: In adon diti. to send.inf the:form to ethed •. . the-addiess(es),above, also submit one copy of this form wIthm 30 days of . , ims.Disinfection vie: Chlorine unt: - .k r• oz. ' where constructed. ,complation of well constructionUr i the county health department of the county • :Form OW-I • North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013 , [ I