GW1--01648_Well Construction - GW1_20240313

. • . WELL.CONSTRUCTION IECORD {_ .
• For Internal Use ONLY: i '
: This form can be used fee tingle or multiple wells •: • • .
1.Well Conti :tor Ittforitation:
BObb �. PO�(fS . 14.WATER-ZONES- • . i
y W. PROM TO . ' r- •DESCRIPTION . • . .
Will CoatiactorNamo .: I ! .
ft. f �
.� •
_ . . NCWC 2O28 A ,: ft ft
NC Well Con Cert,ficaiion Number • •1S.OUTER.CASJNG(Tor muldeasadirdLS)OR LINER Cdaa&alie) .-
.•' FROM '' TO- DIAMETER : THICENESS .MATERIAL
. Ferguson's Welland Pump,. LLG . . n 0 c7 ,, 5,in Z/6,/1.5.. ,(IGSD 2�1 . .
ConwayName . . 16.INNER GOR G(sfaodmalelased-loop)-. . .
• '1 FROM TO . DIAMETER.i. . THICKNESS ' MATERIAL . .
' • 2.Well•ConstenetiouPermit#:. ' . . :a.d06. 4. -. U'b4 I Cp. . . >� ft. I :
•.Listall applica k wall on p rims 6 e.Crriry,Stote,Varimece etc)
• ft tt in .
: :3.:Wal1•Use(eboada wUl nse)e • • '
17.SCREEN.
Water Supply Wadi: FROM'• TO. '• DIAMETER SLOT SIZE .TIE INIRM. MATERIAL _
it. ft •in,
• ❑Agricultural ,t D�'ctpal/Public .
• 'OGeothermal.(Heating/Cooling .D ,•-idential Water Su sin ft .ft. m
,Supply) PPIY( �).
OIndushiaUCommm cial. .., . , . . DResidential Water Supply(shared) ' . 1&GROUT . - "
OIriigation PROM:it 2 R r irtansairtTaRBon 'AMOUNT o mamma: .
Non-Water Supply,Well • • . .• . . • 0:• . . 0 Concrete . ••t Gra L• :
. •OMonitoriug . • . . . . . . . . . ORecovery_• ftto k 1 �d.
Injection Well: • • . ft ft. ( .
•: OAgnifeiRecliarge..' - : • • Ct:irounrivonterRemediarion • •19.SAND/GRAVELPACK6fanode) .tnr0iFs',o:t. �r..� ;�:.�;1 1:�'i • '
. FROM"' TO -• MATERIAL• E PLACEMEN'TMETROD .
OAquifer StoragearidRecovery . ..0S%+linity Barrier:
. - .ft. . . ft:
•
. OA ,i er Test. . . . OStolmwater Drainage . •
o) .
OExp2rirnental Technology • . ,OSubsidence Control �. ft ' P.'
•2R DRILLING LOG.(attechaddi!ticutdaltertfnecesaary) . • . .
OGoutl meat(CIused'Luup) : O Trdcer . • PROM TO : .DESCRIPTION(color,hardness,sollrro<it type,grain one,etc.) :
LGeothzrl.(Heating/Cooling Retttm) .00R (tcolain under#21 Remarks). . • (� fr: ,.75 1t .I. C fay.' . --. : . . . :
• .4:Date Wel(s)Completed:.�` 7 ;,f 7'Well E 4i 75.ft. ?Ti ft.. ' j . ezo(i s CC7e_ .
e .weRLcafia : . . L7s • . .
• � . 6_ '-eUi)ir-71. ft. ft
Facility/OwnerNam^ • . :Freaky IV(if applicable)
•ft. ft. •
.
' m�•t, )1.1661 I /2 1':,:,,1 q�. �.:(U(54.
ti L—irt i1.e ZS.Tfy 1 . 1 ft. • 1ft. I. . • • •
Physic at Address,City;and Zip I EMARR6
County . Parcel Identifieation No.(PIN) .. . .
•SI.La ide and Longitude in di iu aeas a mutLisecora¢ly or decimal degrees: 22.Certifiention:. . . .
.(ifwe i fields,one lM/1/onj is sufrcient) • ' ' . ' . ' •• ' •• -
3.$°VS t.A(s VI' N q'A '2..3> sty" I /574 'w - �r/� e letAry_.--;-- 4 SignafrueofCoitifi7 Contractor. . ,. • • .
•
6.In(::t.e iinewen(sj:. erionma•t. nor OTrtni+otray • ' • thai the well s was ere casstructed in acconlmice. .
By stgrmtg rlrls,forn;1 hereby cerdfj± !)- !w� 1
with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Comb:mikeStandards owl that.;
• 7..1s dale n tent�to an mis+'i g tli: PYc i. or 03Yo • 0 copy of this recordhds bean provided to Nte.well owner . • . . • . .
• •If 6 LS is a midi.,fill blown m.1 rf:ssbvcllon;mfarirzTtion and a phrin thenatroe ofthe .
repoir' #21?MIAS section or'on 1s back oftlds.ihnn. • 23.Site d'ragain or additional well details: • •• • ' •
You nay use the back of this page:to provide additional well site&tails or Well..S.lC eir of wells construcfod: ' construction details..You may also attach additional pages if necessary: ' :
Foi.iivirnsle isna;tion or non-Water.srsoply wells ONfV with the strovecaxshssc&oe,you ce s •
• when'am form . . . - • . . ' SUMMITTALINSTUCTIONS . . •
9.`cal:l weE igslli l;eIoti ..,,;i s,x_'em 1 9 (,) 24a. in All Wells: Submit'this form within 30 days of completion'of well •
• •Fcc•era d aLi•vJwJS 1!t a°l4spdis rf izi:wi nnsrg':�-.' C'? sd 2 00') construction to the following•. - .• . . • .: . .•
.10:Endowater itever below top of sasi g: L"/0 •
~' (ft.) Division Of Water Quality,Information Sassing Unit, :
- ,If imar Se.ke‘lij[rl a.e Slit r't" " - 1617 Mail Service Center,Raleigh,NC 27699-1617 , - •
11,tjc. -hr
sele onier: - • coo , 2c1b.For In,jectiotli Wrelle: In additi.L to sending the form to the address in 24a
. above, also submit a copy of this:foita within 30 days of completion of well . .
•12.Vd.-ii•coisenrainausainetisoit:,,• —- corut netionto.thefolloning: I
(Lc.su.0.5r,rotary,cwblo;dhtet 1r.`s4,um.) , ��.•��
Division of Water Qaality,Underground rground Injection ControlPnsgralis,
• • FOR CU'tzT'L.STZ'1>LY 'F,r•F,3 0 1,7%: • • 1636• .MaS Service Center,• Raleigl,NC 27699-1636
:n3^o.*Dad(grim)_... _ . Ekrellin -Rig . 24c.For Walter Suattly&Injection Wells In addition tri seeding the form to. . :
`bFetla®d of't erg
- tlx�c aaldiu:s(es) above•,'also submit tine copy of this form within,.30 days of:-
(;l'Ilorii/'?; :' • ' 3 .0. z. co letioa of:well construction to the'loounty health,departnoint•of the county
1:3b.M feAm.',yue: ,•t8i:o t:
_ 'where:,constructed
Fora C5:M-I 1 . • North Caroline Department ofEnvironment aid Natural Resources—Division of Water Quality Revised Jan.2013 .. .
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