GW1--01652_Well Construction - GW1_20240313

.
WELL.CONSTRUCTION RECORD • For InfernalU ONLY :f
This form oanbe used foisingle or mnllplewells
1.Well Contractorrnformattun:• ' • ' • • . •
.
:,Bobb W. Potts : • 14.W4TERZONES .: , '.
PROM. TO r •Din RlPi1ON
wo.n contractor lone
NCWC 2028 A.• •.:ft ft. I •I •
. . IS.OUTERCA3 G(farmniti edwelia)ORL1Nl31tfd
NC Well Cant actor Certification Number )AI.
IN
.' FROM . ' TO• DL1MErER I TtIIClOVESS •. _
. Ferguson's Welland Pum LLC ft. `
CompanyNsma 16.INNERCAS NGORTUBING(S maldased�loup)
' /�- /` FROM TO: . DL111®7TR•: .' T1DCENP.SS MATFRLtL ,
•2 w►ell:Coactincplou Permit#• • . Ptva3 " .U Ga o�l. . fG' ft : • ia. ..
.List all applicable:well consnuctl nPerrrdts(re.Cowiiy,SYate,Yariancc ete.) • • - . • • . - . • •
Weft p.se(dtedc well use)h 17:SCREEN,•,
• Water***Well: • FROM: xo DIAM6TElt SLOT SIZE 'Iffit�VE4S' MATERIAL
Pub • ft . ft in
, OAgrieultural ' : . ' : ❑ lic '. . .. . . .. . .
•• OGeothetaial•(Heating/Cooling Supply) ' . *deritial Water SUPPiy(�sungle) • it • ft' '
OIudustrial/Commeroial • • • OResidential Water Supply(sliared) •18.GROUT •- . -
Dhtigatiaa • PROM. TO MATERIAL IMPLAMENTMETHOD a AMOUNT
Non-Water Supply Well 0• •ft 20 Concrete GravityPlow . f,.
OMonitariog ORecovery ft: , ft ++ r La i 1. L .
Injection Well: . ft, ft : 'MAIL 1:; 21174.
QAguifet Recharge. OGro nidwater Remediaaon; • 19.SAND/GRAVEL PACK(if applicable) • ' • •
PROM: TO
OAquifer Storage and Rec`ovecy OFa)ii,ity Hairier : 'MATFRiAL ' � ' tnt�����.�,,�,°�D�,;.,y •
O er Test ft' • 7- • .. • ,
p!� ❑StomtwaterDtainage• •
• DExpetimental Technology DSubsidence Control . ft, •h : p. '
20.DRILLING LOG.(attad�sdd76mal atazm ifa
OGuuthermal(Closed Loop) DTracer : • : ' PROM ' TO •Dr/A'O ON ccolet hardnrrt,soNtbctrtgpe.Wand=e,era) .•
OGeothermal(fieatrag/Cool(ng Return) OOther(explain under#21 Remadcsj. . t�. .ft, 20.. . • . • •
4.Date Wells)Completed:r7/2v Well ID# • •R. J
�.WenLowhton:� • • • • • • •/�
Faci(ity/OwnerNamc Facility D#(if applicable)
R. it
� 'Iut,(<<y arec:IC 1-e s .aA1Q . :ft. • •
- .
• Physical Address,:City.and Zip: . •' `
zt.REnrARss
County Parcel identification No.(PLAT) .
' Sb.Latitude and Longitude in degree mnnte•s/second•s or decimal d
(ifwell'bid.onelalliong is suflicierit) 22.Certification:.
N' $1?; :3
:Si of eat WdI Contractor
6.Ia(*)'the well(s)::QPermaneut or QTeurporaty. • By stgiang this fount I hereby a�hfy that the wel/(s)was(wer e)`boudueted tat aeeoxlance '
•` ••' '' : ' , with 154 NCAC 02C.0100 or 151'NCAC 02C.0200 Well ConstuctionStandards and that's
7.Is this a repair to.an ezisti ng,wet:. Oyes. or Ql�o :copy of this recordhas been provided to the well owner.•. • . . . . • •, . ' .• ' .• •
rthtsis a?spa?,fill out/mown well can5mregon information and explain the nature ofthe '• •
• r pair wider#2l renarla seciwn or on the back tethisfovns 23.'Site diagram or additional well details:
: / • : You may use the back of this page•to provide additional well site details or well
S,Ntinthee of wells constructed. •• 'construction details..You may also attach additional pages if necess n). •
For nsulllp ecilou or non-water supply weils ONZYwfth the same couairsatwe.you cmi AL I, • •
sabnazl ormfwni SUBMITT INSTUCTIONS
•
9'Total well depth below land stufacr s��' O.(ft) 24 For'All Wells • Submit this form within 30 days of completion of well •
Forme pie wells list aUdepthsVeit/e,cnt(exmnple-3Q200'and2Q100) construction to the following: :
• 10 Static water keel below top'of casings. . • (ft) Divlama of Water Quality,]information Prucessiog Unit,
,ifwater level is above east,g;use"+ • " '� "" ..
1617 Mail Setvia Curter,Raki�t,NC 27699-1617
11:Borehole diameter •*. •' ' , (in.) • • • 24h for Tnieetion Wells In addition to sending the form to'the address in 24a
ROta • .• above,.also:submit a.copy:of this form within.30 days.of.completion.of well
1LWellconstructionMethod: ry construction to the following: ,
• (r.e auger;rotary,;eable,dntct push,eta), 1
. ,, , . .. .. Division of Water .' • . •
' Qnality;Un�ergromsd Injection Contras Ptageata,
FOR WATER SUPPLYpWELLS ONLY: .. 1636 Mail Service Center,Raleigh,NC 27699-1636 '
' 13a:Yidd(gpm) oC o Medved of teat Blowing-Rig • 11- For Water Sunni*:&Intectui �ilella: In addition to;sending the fotnr to
•' , the address(es) above,also;submit one copy of this,form within.30`days of.:'
13h DLtinfecbion type: Chionlle Amount: .v ' •oZ '• completion of well construction to the county health,department.of the county, •
. where constrpeted. J
• :Form 6W I Noah Catellna fepertmant of Environment and Natural Resources=Division.of Water,Quality Revised Jan.2013, .•. •