GW1--01633_Well Construction - GW1_20240313

,WELL CONSTRUCTION RECORD For Internal Use ONLY: 1 ; •
'This form can be used for single or multiple wells: ., .
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1.Well Contrutor Information: .
Bobby W. Potts•_ . . 14.WATERZONLS • .i -
Y .. .. PROM Tte-O i DPscP T10N . . '
Well ContragtorNom: ,. „ :. ft 'COO n I i .
NCWC 2028-A :: tt: n
.NCWellContiactorCertificationNumber' ' - • 15.OUTERCASING(for nmWi;eatedwdla)ORLINERCda He)'' .. . . •
FROM • . TO . . •' DIAMETER THICKNESS TFRIAL,
' . • . . Ferguson's Welland•Pump,LLC . • . . . . ' , h . •.7g ft• (t; 5 `n• •2/(J C•S / .
CompaayName . . 1 1NNER CASING ORTURING(uedltrermaldaseddooP)
•
j� FROM. TO •DIAMSTFt2 : •THICI�7E4S••' MATERIAL
•2.Well.Constnncdon Permit Ni. • el :c 5 :p of 0 a :..[110�_5. : ft ft m . : • . -
List all,applicable well ct►sbvction pemdts(Le.Cooney,state,Yarimnce,etc.) iG ft io
• :3.Well Use(check well rise): . 17.SCREEN . 1
Water Supply Well: . ' . . PROM-. TO. '. DIAMETER' SLOT ME THICitrtESS. MATERIAL •.
CLA nculhaal. O�cipa1/Pubhc • ft ft i'n •
EGeothernial(HeatingiCooling Supply) .G4tesideattial Water n • • • f ft? ' 'n' . . .
�PPIYsi
(single)..
. .Dindastrial/Comnteneial °Residential Water Supply;(shared) 15.GROUT _
!]Irrigation •• W. . FROM '. .TO .. MATERIAL •.EM�LACO:KENTMETHOD'aAMO@iT.
Non-W Wall: 0. ft. 20 . fe• Concrete:-• Gravity:Flo�v
°Monitoring . ORecovexy • it ft Le�. lc„.
r • ft. ft
• .ClY""fenr R ch e. ' ❑Groundnrater Remediation'• - 19.SAND/GRAVEL PAPACKfd' e) M ' •.. (. ' •.FROM.' TO . . MATERIAL . . .F14�LACENIIIPT.MLR'HOD
.DAquifer:Storage and Recoveiy•• • .•!Salinity Barrier . . . ft • . •.ft ; . u1 uv.rr em,,.c,r r:::,;.ytxi ,'s,•ISRiG.
`DAquiferTest -. . OStomiwaterDrainage , • . . . DANC., rkw'
•
R R
. DExperimental Technology '. ' °Subsidence Control ;
• •20.DRILLING.LOG.(attathadditdmal sheets 1f try'
' •l7Geuthetmal(Closed Loop) ' . • DTraixr • - • FROM TO fESCHIP ION(tutor,t ardness,rdWrock type.min du,eta) '
°Geothermal(Heatiag/Cooling Retinnj . •°Other(explain under#21 Remarks) O. .it .it : eray ;
• • • 60ft .70 ft - '' gaff,Axe:e • . . • .
.4:Date Wells)Completed: ��/�/Well IQH •• 70'. . St
5a.Well Locations R t • /G//
G
t<01ron. lit)rt' kJ-. . • , � . . '� f • . . .' . • l . .
. Faei(ity/Owner Name . •". • ' Facility DM(if applicable). .. .
..a(ol: Fern 06kA Lantz 1APndodbnuillr a,riq a ft . ft: . '.
.
Physical Address,City;and Zip:'
�'�tin,/ersar� 010.045. 35(071.
County Pareel ldendficatonNo.('PIN)
SSb.Latitude'and Longitude in degiees/nainutes/ceconds or decimal degrees: '
- . (ifviell field,tee;lat/lorig is sufficient) 22.CertiScatio• , .` .
�� 73igmaue of Certifi d WeII Ce' min
::6..Is(are)_thewell(s)::QPermane:i •• or ,OTemporary: • •'
t. :. • • . By'sigtatrg tits jomb 1 heri:ify aerOfy aUai the weU(s)was(were).eorWrrre�In aeibidmtce.' ; .•.
• . . . with 15ANCAE 02C.0100 or ISA NCAC 02C.0200 Well Coiutnactio rStandards and dun a
• . . 7.Isthisarepairto.an:existingwell: °Yes . or l l '. . 'copy(etas recordhas been provided to'thewe!!owner . .• , . ' . . . .
• •:(flirts is a repadr,f 11 aid known well construction bfatiration anderplasirt the nature of the
trpdr logger#21 tnxmkssection or on the back of thisfonta23.Site diagram or additional well details:. '
• , You may use the back of this page..to provide additional well site details or well : -•
. 8.•Number of Wei;eonstructed: ' • • ' . • • • 'construction details.•You may also attach additional pages.if necessity:` .
ForimultipleWeation or non-walersupply wells ONLY with thesaatecoits ration,you eon •' ', '
sabndt ce efan s. SUBMITTAL INSTUCTIONS •
9.Total well depth below land surface: ' ' - • (ik) 242: For All Wells: Submit this form within 30 days of completion of well
For:muliple wells list all depth's tfelenmt(exmnpk_30200'and 2Q100) construction to the following: 1
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10.Static water level below top of casing: •. e2 '''• (ft.) • DDivision of Water Qilality,,Information Processing Unit,
..Vwoterkveiisabar easing use"+"• 1617 Mali Service Center,Raleigh,NC 17699-1617 • '
11:Borehole diameter., f` 4 (in.) 241;.For Tniertion WAS:. In addition to sending the form to the address in 24a . .
above,.also submit a.'copy,of this;foim within.30 da)s.of,completion of well : ,
12.Well:censtruction method: •Rotary . . . construction to the following I .
(La auge,rotary,cable,direct push,etc.)
- . . . . Division of Water Qoality,•Uadergroimd Injection Control Program, • •:
FOR WATER SUPPLY WELLS ONLY: . • • • • • 1636 Mail Service Center,Raleigh,NC 27699-1636 • .
13a.Yield(gem) -Method of teak Blowing-Rig . 24c.For Water Sunny&Tniectinn Wells::In,addrtion to sending the fog to,:),r • .
the address(es).above,also submit one copy..of this,form within 30 days of . °e
• .•. 13b.Di>rmfection type: Chlorine . :' . .Amount:-. •..5t2- ..oz:. .'completion of well construction to the county:health.department:of,the,oounty.
• .where constructed. 1 .
Form Cw-1:• . • : North CamlinaDeneronent of Environment and Natural Resources-Division of Water Quality •Revised law.2013. : •