GW1--07395_Well Construction - GW1_20231117

. WELL CONSTRUCTION RECORD . . For Internal Use ONLY: : .- . . •- • • ' •
This form can be used for single or multiple wells : . • • ' . .' .
1.Well'Contsucter hnfortpation: . : • • • - . .
.'.Bobby W. Potts. • ' . 14.WATER-ZONES,.;• . I.:
_ - .Y FROM, TO r DZSCPJP9TON .
_:.Wcll CoatraeWrNa•mp' .;: . . . :. . • •. • : •• • . ' •f dr�ft 1. .
: • •:: NCWC 202&A .: • • 'tz � ft .:.. I , .
uNC WellContiaemrCertificationNmber IS.ODTEAASNG(for Mul wrlls)OB11Nitfd I .
FROM TO, DIAMETER '. THIC�rFS4 MATERIAL,
. Ferguson's Well and pump.,..LLC co ft.. 7 ft. 4.,k5.•, ?,r , ' d21/c5�2 1. . •rn
• paayName ' ' R
a TO
16. G O TOSQVG(aeb�rmali3daed - .
. ./� ,� FROM.- 'DIA11�'1'F.R . :•TBICIaVE44•' MATERIAL ..
2.Well constiuodon Peewit#:'. - .5`SJ• -2 0 2.3- /6.35.. .ft.' .• ft I inn. . '
List ail applicable well metbueAon peredts(te..Covely,Stare,Yotienca,etc) . ''• i .
. tG ff:. • I.
''. in
' . • .3.Well Use(cheek welluse)e . : • . • : • • .
Water Supply.Wel:
.• FROM TO• DIAMETEIY SLOTSiZE 1>DQdVF88• MATERIAL
❑ cultural .. .. ft ft L .
+� . . ❑ efpUPublic . . . . � .. .i • . . . , .
'❑Geothennal.(Heating/Cooling Sapp-.1y) • C tial Water Supply(single).' it It'• ' ' f • •• m • '
: .pIndilSltlal%COmme[cial. OResidetttial Water Supply:(shared) .. .1a ROM our•TO .• MATERIAL• '` EblPLAC!MENTMErHOD&AMOUNT. • :'•'
: . Ohligation ' C• fete .
Non watersoppbrwdl:: 0'. �` 20 one Gravity-Flow
OMonitoring. ❑Recovery_ ft.'
. Injection Well: • • • • • • • • • ,ff.: ft • • . ;• ' : '
❑Aquifer Recharge - • • ❑Grouudwaati rReraediation -:•• • . •19:SAND/GRAVEL PACK(if thelhoaldc) ' . ' . .
TERIAL ia5PLACH ENT
❑Agtufer Stora&o and Recovery:' OSalmity Bawer
. :' FROM TO MA METHOD:•
• '°Aquifer.Test, . • . . • OStotmwater•Drainage . • •
.
' . -2.OFatperimemal Technology ❑Subsidence Control D'•
•ZaDRILLINGLOG.(attadtaddttl�alaba0stfaeerssaty) .. . .
OGeuthermal(Closed Loup) OTracer ' PROM .• TO : DFSLI ON(color,hardness sate a type,grain dee.de)
OGeotheimal(Heating/Cooling Return)' Other(eitplain under#l21 Remarks). ft :` .
.4:Date Well(s)Completed•. • 1 • 3 Well roll • • _ Y (. f` =S q`r4 ? fvc
r .ft.. • f. .-U p .tin
Owns Name , t ua ..
Faci(it}i/ - � . ' FaeilityID#(ifappliablej. � - .::?:... •
PO .1- i202.3. •-a 1p,: :l3to4OrN • 1.J4 it-Ue ,S,e'rCtii:v1i`(Ill'02g.7La . . .• •ft" ;• •• • .
. • Physical Address;City and Zip • • • '
(,4"• ie�r5(tir e��G t y 5l0$ -7 21.Rzras . . .:>� t c .
5 4.-'
County Faunal Identifea[ionNo.(PIN) i.
Sb.Latitude•and Longitude run degiees&unntes/eewnds or decimal degrees: 22,Cerfi•fica•'on• - . .
(ifwTell field,one letllong is,sufficient) • •
• . 3s • �3` .30 t .niN• 52..AS .Z.$',3 r5A: . W ' .e . . ( . 3. . .
:signature of ed Well Contmc r i.. • .1> • .
6.Is(are)the wek(s):: irrmaneat•. or' ,❑Temporary, •, . ' ,B3'sigrdng this farnb 7 heraby certify that The weA(s)was.(wen)coristra:ted ter areoidmice
• ' ' . with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well ConstructlmStandards and Aunt a
. . 7Isthisarepair titan'mistingm:al:•• ❑Yes • or •❑No• • • . . 'copy ofdrisrecordhae been pravicadtothewellowner.. . . .• • . .
•.Mists a twit:10ll out to own wilcovam :ion brfonitation and explain the nature ofthe I'•• •
repoirwider#21notelssectionor'mikebaok.tft is ono , - ' 23.Sitediagramoradditionalwelldetails:. '
• ' '• ' You may use the back of tins page:to provide additional well site details or well ..
:• S.Number of wells constructed: ; I• .• ' • '• ' • construction details.;You may also?titch additional pages if tiecessar}
FornwWpleWa:doriornwr-water Op*wells OAZY.with the.stone eteutraction,you.cirri ALINSTUCTIONS.I - .
suburbaiafeim` SUBMITr . . .
.
•
• " 9 Total well depth helot,/landAkiAkita.; •' S'`' (ft.) :24a. For Ail Wells:• Submit this form.within 30. days of completion of well
. ' •••For weile.1ist al1.400..YdD erw s.6ica apler,3(200'a 2Q100) •• . construction to•the following: .•
•' 10.Static water level below top'of cashig.•• •• • 4/l.J •• • •(B.) Division of Water•Quality,Informateon P•roceasmg Unit, . . .
If wateilevel is above casing;use"+"' / -- ' 1617 Mail Service Center,Raleigh;NC 27699-1617_
11:Borehole diameter •,,,-
``''. •. Cm.)• • 24b.For leiention Wells: In addition to sending the form to'the address'ia 24a . .
:.. • • ROta • • • • • :above,:also:submit'a.copy.of.t1n form within.30 days of completion of well :. .
U.Well w . construction to thefoliowing. . . .
nsaadwn Method: : rY :. • .
• '- (ia;huger,mtary,.cable;duectpush,ete.). .• •• ; '' .•. '
• • . • • ' ' ' • • ' Division of Water.Qaality;Underground.injection Control Ptagram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636. ' • . .
•• ' ' - Yield' • • Blowin -Ri . :24e.For Water SuMily Bt:Tn ectimi Wells: In addition to sending the foan.to . '.-: .. . .
• (gpn<) Method of teat:. • •g • ' ' the address(es).above, also.submit one copy of this:form within.30 days of''
13•D;, section :-ChIonne.:: �t�• ;:. ' •Y 2. : • •Oz. completion•of well construction to the county•health department of the county.
• -•where eonstnlcted, .. . . -
• : Form CW--A:: NofthCmluna aDeparmientofEavuoaent mand;NaGualResoiuees-DivisionofWeter.Quahty Revised Jan.2013 :