GW1--07435_Well Construction - GW1_20231117

' wzia.,l.;VrlmlxuCrit rr iu cOnxi . . ' . For Internal Use ONLY: ' 'i •
This form cah be used far tingle or multiple wells. • .
1.Wen:Contractor Information: • ' i, •
Babb .:W. Potts. - . ' .
' . •U.W4TER201vES � t ,
Y •' FROM • . TO. •• , DESCRIPTION. . . .
WellConhaetorNamc + il . /LIDO R I i.
'N:CWC 2028=A••• ; .• • . /`f o • .
'. NC Well.Contraetor Certification Number . - . . • . . . . ' . . . . ` 15.OiJTER CASING(for mniti ssodwills)ORLINEROfanpIcable)• - .
' • -PROM . - TO -. - DIAMMER. ''THICKNESS'' MATERIAL ' '
.- Ferguson's Well.and Pump LLC • ' . - • • .- • ft ft. + h. .. '
. ' . :Company Name . ' • . : . . . . 16 G OR TUMGIsteithermal dosed-loon) .
'' /� PROM TO DIAMETER TSICKNE S MATERIAL
2 Well Constriction Parent ::: ' '•• c C) O 9 ..ft . ft. • in. • . '
List all applicable well coecrlmclionpemtits(Le.C 3 _ ' - • .County,State,Yarimtctti etc.). .
fn ft in .
3.Well Use(check well use): 17.5CREEN
•. Water Supply Well: FROM To DIAMETER SLOT SIZE. THICItNESS MATERIAL
❑Agricultural:: O eipal/Pubhc '
it ft in•
OGeothermal(Heating/Cooling Supply) . esidential Water Supply(single) . . ft . . ft . - , ,
. ❑Indushial/Commercial • ❑Residential Water Supply.(shared) 18.GROUT
Olmgation . . . . . t ft
FROM TO MATERIAL EMPLACEIWEN'CMETBODB<AMOUNT
Non Wihr So. - ow - .
pply will:: 0 f 20 . .� Colicrete Gravity.FI
❑Monitoring. . . .. ORecovery .. . . . ft tt
Injection Wells ft
❑Aquifer Recharge' .: : . .:. . ' . . OGroundwaterRemediatiou -. . 19.SAND/GRAVEL PACK(danolicaile) •
❑A er Storage and RecoV • ' PROM TO MATERIAL EMPLACEMENTMKIROD.
quit g cry. • •OSalinity Barrier • : • ft . . ft: . . .
❑Aquifer Test ' '' ' —• ' ' ❑Stotmwater Drainage ' . ' . '❑Experimenta '
l Technology "'OSubsidenee Control ft o
70.DRILLING LOG.(attach additional sheets ifncoessm9).
• .❑Geothealnal(Closed Loup) . - ❑Tracer , FROM ' .TO R. . . •DES IPTION(color,hardness,wlUroclttype,graind:q'et�) .
DGeothennal(Heatiag/Cooling Return):: ' ❑Other(explain under Nil Remarks) - • . . .
ft
4.Date Well(s)Completed: /Q LA :7 Well ID# • ((((((IIIIII'''"' .
•
:Sa:Well Location:• • • • . .•• -;` • • ' .
• �`; •:ft: ••) eft (Q./tt.•••• ft :' •. ••
••ten A .- e cchei�.• : ?. ft. . ft.. . . ' 1' ' . .' • . ;
. •:FacilityfOivner Name , ••. Facility 1Db,(if applicable)
30 ciii tlts0ift• r:Dri,'u e . Le iie84 ag lw e . .f' :ft. : • .—~ :' , •
PhvsicalAddtess,.City,:andZip. 1: " ;
• - •' 21;.REMARKS. . . :,�, �'�t- 1 r ': .a- :.n:,:.� . . . .
. btllrbn.,b.t. q i ba y 1
.501.n. . . • . . . . . . • . . . . : • .No.• , 7 ne:. mot) '
County" Parcel Identification No.(PIN) • . ., .
• • 5b:Latitude and Longitude hi degrees/minutes/seconds or decimal degreeso-
•
.'
:22.Certification weu C .';1
7 L
(ifwell,field,owlet/long is sr�cieni) �. -_ 'Jr
• • .
?'5°e/' .or736Noos 72w • - 4ty,•,,,,,,?2c-•--. . • •
•.:
: n , 7:6.Is(are)the well(,)
eranment -•or ❑Temporary:
•
: By igrfiitlris fount.'heiebp ea*that the weU(sJ was.(were).cwasJructed in accotdmree. : .
/' with ISANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Starrdarch mud theta '
.7.Is this a repair to an existing well: :•• OYes or .ONo . - . copy of this record ha been provided to the well owner.
' • If this lea repair,Peat brown well eotubUc o tion is mtation andesplain the nature ofthe ' ' ' • ' ' . • • '
repair under#21 remarks section or on the bade of thiifoam . . '23.Site diagram or additional well details: . - . .`` ' - .
•' •::S.Number of wells Constructed:• . . .'. . : . l'• construction details. You may also attach additional pages if nescessai)
You may details or well
• . .
. . ' •For,natltiple by-eaten or non-water supply wells ONLY with the saute construatwn,you can:' ' ,'
sabirct orieforrrs SUBMITTAL INSTUCTIONS
9.Total wen depth below land.sueface: ' .1 gS • ' • (f.) ''24a. For.All Wells:. "Submit thin form within 30 days of completion of well-
Forntaltiple wells list all depths iftf�erent(excenplee 3®200'and 2Q100') '" . - . construction to the following:• • . - _ •
• 10.Static water level below top of casing:.• Z V . : . . :(ft.) Division of Water Quality,Information Processing:Unit,
If water level is above casing;rise"+" • : • ' . • '' .' 1617 Man Service Center,Releigh,,NC-27699-1617 • -
. ' 11.Borehole diameter: :``. ' . (in.)., • - • • . • ' 24b.k'or•'Ii;ie ction Wells:"In adiilion•t`'sending the'Form to the address in 24a '
'Rotary . above, also submit a.copy of this;formf•within 30 days of completion=.of well '. ,
:12•Well construction method: • . rY •• : : :cunstructiim to the following:
(i.e.auger,rotary,cable;.direct push,etc.) .
Quality, • .!1 .: ; . .•e •Division of Water Underground InjecttoPs Control Program, .
FOR WATER SUPPLY W.EE�LLS ONLY: • 1636 Mail Service Ceater, aleigh,R NC 27699-1636
. 13a.Yield(gpra) ' : r/ V ' : Method of test+ Blowing-Rig' • 24c.For Water Sudnly&Infection Wells:'In addition to sending the form to • •
• • •the'address(es)'above;:also submit one copy of this'form within 30:days of
13'.- .. fectioatype:.Chlorine ::' ' Amount:. • ''4 oZ; . com•pletion of well construction,to the:county health department of the county. . ••
• . . . • . . . . . ere co t• • • tt
wh nstruc ed
Form OW I • . ' . '. North•Carolina Department of Environment and Natural Resources—Division of Watisr Quality 1 • • . Revised Jan 2013