GW1--01627_Well Construction - GW1_20240313

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WELL.CONSTRUCTION RECORD ' -. • • For Interoal.Use ONLY:
.• This forth can be used rsinle or niultiplc wells - •
•• .1.Well Contractor Information: : : • . : .
Bobby W. Potts 14.WATERZONES,. . . I I •
7 PROM TO r DESCRWIION
wen co, :wrNaom '�: 3 SfQ . `L k.
• NCWC 2028-A :: . .; ft if5p t
NCWeUContrietorCcrtifieationNrimber 15.OUTERCAS Eta(for n likesedwells)ORLINBROf ) . . . •
' FROM . TO. DIAMETER I . THICKNESS MATERIAL..
Ferguson's Welland Pum LLC • ft.
CompaoY.Name - 16.INNERCASINGOR TWANG(ge6�ermaldsscddou4) .
PROW TO. . •DIAMETER.. . THICKNESS' MATERIAL . . .
• 2.Well.Consavebion Permit#:' A.3:ea .. t O.7[O" .• . . .' .ft• .-•• • •. in.. • . . .
•:List all applicable well construction (I.e..Cotmty,S'Iare,Yarianee.etc.) • .
iL ft..
' . • :3.Weil Use(check well use): . •. . . . . : . . . . . . . . . . . 17 SCREEN.•. : . . . .•. . . . . . . .
Water Supply Wcth .•: •. . • . • .-. ... FROM'• TO •- DIAMETER' SLOT ffi2E •TAMENESS MATERIAL
❑Agricultural /. ❑ tpa]/Public
•
tt ft is
. • OGeothennal(Heating/Cooling,Sttpply) . esidential Water Supply'(single). ' . . • fp .' • •
❑Industtial%Comthercial : • OResidential water Su 1 is.GROUT •PP. ( PROM TO. MATE.RIAL : EA�LXCH10+1HT.MLRHODd<AMODNf
oln Waon
• Nonw ater s>;pply wen:.� • . . ' . . ' . . 0 . . . n20 f< Concrete . •Gravity-Floii`
fe,OMonito' 8 ORecovery
=r�r• :
W. .. 202
•IgjectionWell: - . . - • fL. ft • •: • • '
:DAquifer'Recharge. • : •• • ❑GrougdviaterRemediation• '19.SAND/GRAVEL PACK Ofimilicelde) ttH7:c.ri;;;en.:ar^.�•y, :,
FROM TO MATERIAL F1�LACEh9+1VTMLTFIOD .
• .OAquifer Storage andRecoveiy . : ❑Salmity.Hatrier : -
fc ft:.
OAquifer Test . O Stomiwater Drainage
O13xperimeaWTeohnology DSubsideaceControl �DRILGLt>G.(atrxhad�ltiooalaba6sii>r . r' •
• OGeuth t Pus:4I oop) DTracer ,• • • .• : .• FROM .• TO .• .DESCRIPTION(edpr hardness, grab dee,etc.)
• OGeothermal(Heating/Cooling Return) ... Other(explain under#21 Rernarks) lr:" D. .ft • !. ;e r(a .
•
• 4:Date Wells)Completed: ) / WeIIID# •• •
30",fL: • 5 f•t• •sah4E5*ez/e . • •
: . . • Sa.weII Loca�aat • t
• 7.p. t1%'l�e((_'ta nA6 r o (rt4i b l • S •tt. oZft.
.
Faeiht3'/OwncrName. • ' FaeilitylD#(ifapplicable)-. R . . .
�ho�sp�r►.I i i•: fhi ft.
Physical Address,City,and Zip.:
21:
f/l
REMARS Gil[.i 07q , op[ H .
•
County 1 Panel+dens on No ((P)! !.
56.Latitude and Longitude m degrees%nmtutes/seconds or decimal degrees: ' '22.Cerlif•cafioa:. •
(if well v field,one tat/loag is sufficient) p.:. . "
' ' t( � t: • it • •
i.
Si tun of Cer• a Well.Contractor Da
6..Is(are)thewell(s)::QPermanent.•or DTeuopoasy. . . ; ' By'. ,signhhtg tfds join(7 here •that ,tlu wells was.• rby certlh'. (J. ' (tvehr:)•cauirirtted rn aceoidraice. •
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well ConitinctionSYarrrdands and theta
• . 7.Is Ibis a repair twin esiSfmg:welL•. OYes. or o. . • . . . • . . copy ef7htssecordhasbeenpmvia'edto the twellowm. ••. . . . • . . .• .
. {fthisis a repair,fill out 1asown well construction tn¢amation andesplain the nataie of the
• repairroider#21 re naiktsa+ctionor on the back ofthisfonn. 23.Site diagram or additional well details: •
: You may use the back of ties page,to provide additional well site details or well :
8:Number of weIis eoasteuctede ' ( • ••• • construction details. You may also attach additional pages if necessary.
For mWtiple b#ecdoriornon-water supply wells 9NLY.witlt the santeeasilruMion,yoir cmi . • li
subnatcnefmn`• 9:Total well dep8t below land'surfacer • S '• (ft). •24a. For All'Wells: Submitformwithin 30 days'of completion of wellFornnildpkwdlsitstaUdepdrs tf'�emrt( pie-ZA 0.0'mrd24100) •_. construction to the following. I i .
'• 10.`Static water level below'top sof cosine •• y • . " (ft.) Division of Water Qualfty,Information Processing Unit, .
.[water kveUs above casing use"+" - • • • 1617 Mail Service Curter,Raleigh,•NC 27699.1617 • • . •
11:Borehole diameter: .` ' 4 . (m.) 24b.For Infection Wells In addition to sending the form to'the address in 24a
ROfa. • above,:also:submit acopyi.'of.this**?,within 30.days.of.completion.of.well. .
12.Well:a instruction method: • '7 . construction to the following:_ •. .
(i.e.auge,rotary•cablg direct push,,eta). .
Division of Water Quality,•Underground;injection Control Pmgraam, •
• - FOR WATER SUPPLY WELLS ONLY: . • .1636 Mail Service:Center,Rakigtt,NC127699-1636_. .• • •
13a:Yield(gpn) • 5 • Method of test+ Blowing-Rig . • . 24m For Water Supply&Inieeti as We1L. In additton;to sending the form to
the addresses)above, also;submit one copy of this form within 30'days:of." .
• 13b.DismtEction type: Chlorine •.Ataoumti • . oz: completion of well construction to.the county health department.of the county
• ( .where constructed.
Farm C-111/-1'. North Carolina Department of Environment ana.Natural Resources-Division of Water Quality Revised Jan 2013 :