GW1--06465_Well Construction - GW1_20231002

WELL CONSTRUCTION RECORD P 1
• •: This form can be'used forsi gee or multiple'wells • .
: •For Internal •Use ONLY: :
• .1.Well Contractor Information: • • • • : : ' - •
Bobb 'W. Potts . - 4TERZO ES :• . .1
• Y . 14.WFROM. TO r` DFSCRIpTION
Well ContiactorName . - . . . . fe a . . . . ' '
NCWC 2028.A :: ..:: • -
NC Welt Contra—ctorCetifica:ion Number • • • • • • •1S.OtTCERCASING(for mtdfietsedweIs)ORLNER6f ) •
FROM TO• DIAI1dErER THICISS MATF1tUI.
• Ferguson%Welland Pump, LLC • • 0 . 3S (,t 'M•b. 2/6o1A ftc51).i 2O
CompacyNamo . • • : •16.INNER CASING ORTUB NG.( ma1 doied,lwia) .
a' �i - 1 PROM: TO•.' :-DIAMETER THICKNESS' MATERIAL -
2.Well Conatraedon Permit# l L` L 3 Z .
List all applicable well caashvcdonpemrits(r.0 Coro*,State,Varrwnce ate) . ft
3 Well.Use(chedt we11 nse)t . . • : „
.. . . .17.SCREEN.•. ... . � . • . , , , . . .
Water Supply Well • FROM:• TO DIAMETER SLOT SIZE •TRICFOVE93• MATERIAL :•
D+Agcicult»ral' paUPt blic
• OGeothe nal.(Heating%Cooling Supply) • t'•1Residential Water Supply(ogle) • • ft' • ' • R . •
• Olndusttial/Commereial, ,:, , ' . OResidential Waters (shared) is GROUP
uPPly. •: •FROM. • TO : • MATERIAL MTI:ACEMENTMLRHOD&AMOUNT •
Olirigatiam : . • e to
Non-Water.SuPply:Wdl:: .. .. ' . . • . •
� Zp ft- Concre Gravity-Flow
gMonitoring ORecovery. . fa ft.
. Injection.Welk • :fp it
°Aquifer:Recharge : • OGrounddtater Remediation • • 19.SAND/GRAVEL PACKad el • • ' • - '
DAquifer StorageandRecovery , •OSalinity.Barrier.• . •' . .
FROM'' TO MATERIAL • E IPLACF.MEI�T1'MRCROD'
. •DAqulfer Test. . • • OStormwater Drainage . •
. OExperimeatal Technology ' . OSubsidence Control . R. d
• 20.DRILLINGLOG.(atl>tr addddand�etsifncemars)
OcomMormal(Closed I:oop) DTracer FROM. TO .DFSLIOP ION(coldr,bardneu.wtthoctr Me.VIM the,etc)
• .. OGeothesmal(Heating/CooliagReturn) Daher(explain.under#21Remarks). O ft :' .ft • ; Ca ay. , • . •• • . •
' .4.'Date Wel(s)Completed: +� A• Well]0�#• • • 4 /r { C
5a.WeII Lotstionc• . • .• . . �iG. -tt .. I � -
•
34'' to t�5 Ce_n�'( )F•tc•.. .
A '•E 14w►' 17c-F1.1J 41 ft. ' rt
• Faci(ity/OwacrName - • • , • • Facility ID#(if applicable) • • `
. ft t • ' +
r � • '' 't.:� �E. �� Fri Ate,.i<:
U :TPat�'l: ' V\A&4�gh1i �( ...' tt: •. . 'ft' .
Pltvsical Addctss,City;and zip:. • . •• e Z1.RBAIARF O C T 0 �i 20 23.
I(� ► '.saw 6�84i- q1- �lG7�
.County . " •, • • parcel Identification No.(PIN) • tit"".7 ,
• •. Sb.•Latitude and Longitude in degreeshmnutes/exronds or decimal
degrees. '
2 .Certiicntion:. :' • t
•
fwal field,one lerloagssuffieiart) •' .•` . • • •• .
3 5°iA Q2 826:56 i�: 'N' g2°• S'T e •.® 56.:' • W ef. Le/. , • . . • •
• • � .Signature of C Sed WcI Contactor
• :6.Is(are):ohawell(s):•Birarmanent•'or ,OTemporary. . - // 3'
. ,., '. ::: . . ::: ' : 2�lgrwrg thiCfomR!lfereby'cm*that the tr�(�)� a•
.as(were)caadrucled to accor•dairce'
• !SA NCA 02C.0100 or 1SA NCAC 02C.0 ell CorutrUCfien'Standards and that
7.Is this a repair to an existing well:• OYes• or •emu. • . 'copy of this record hits beenpmvtded to,die.well owner. ..• .. .
''.(fthis is a repdr,illl and blown well cotitruelion irfamation and explain the nature of the - • . i`• .' .
' raorreolder#21rona*sectiongrim the backgfthtsfotn. , • 23.'Site diagram or additional welldetails:
• • ' You may,use the back of.this page to provide additional well site details or well:
. ' •S:Number • •• : •construction details.•You may also attach additional pages if necessary:
Fornmdiple irpectiori ornon-watersyppiy wells ONLY,with the some construction,you cmr • • I;
sabrrctiv.efonrr' • SUBM1TrALINSTUCTIONS L .
9:Total Well depth below land surface: n/) (fk) 24a. Toe All Walls: ,Submit tbia form within 30 days of'completion'of well
.• Formuhiple wells listall depths ifalidengd t leerranpl.-3�100'and 2@100) . . . . • construction to the following: , .
10.;Static water level below top of casing. . 2 0 (fk) • Division of Water Quality, • -•Processing Unit, .
If eaterlevel is above eating,arts"+" . 1617 Mal Service Center,Ralf,NC 27699-1617'.
•
• 11:Borehole diameter: -` . (Q. (m.) _ .24b.e'er injection Wells: In additionto 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 limbod:: .ry : :' • :amstzuction th to e following:. .. • .
' (r.e.:auger rotary;cable,dtnet push,etc.) •
'• .. Division of Water Quality,Umdcrgcnnd.brjectioreCondrolittogram, -
. • FOR WATER SUPPLY WELLS ONLY: . ' • .1636 Mail Service Cetater,Rslcigy NC 2769971636 • • • '
re• Yiebl(Spy • Method of teat:'Blowing-Rig 24c.For Water Snub&iniection.Wells: In'addition to sending.the,form to:
the.address(es):above, also submit one copy of this form within:30•days of
13b• Dlsinfectioatype: Chlorine, • - •• -• •`-A A.:• 'conviction of well construction to the county health department of the county
where cnstntctett.
Form OW-1: North,Carolina Department of Environment anti Natural Resources—Division of Water Quality Revised Jan.2013. ... •