GW1--01654_Well Construction - GW1_20240313

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. • . WELL:CONSTRIICTION RECORDF • -
• orItrnl•U •
ONLY : • '
This for ein be usedforsingle or Multiple wells i.
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• 1 Well Conttndor Information: : • . • . }
14.W4TERZONI . I t
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Bobby W. Potts • . FROM To . r. :DESCRW 1ON
• well coatrhemrWnme :. • ' `100 ft * • : I .! ' : . . : • . • •.
: . NCWC 2028-A . >; ft tII r, ft _' I. : . .
NC Weil Contactor CerffcalionNumber 1S.00TER VG(iotmnVtmedwds)013LNER6id )
FROM To • mu�rmi TlacxivFss MAT132IAL
• Ferguson's Well and Pump; 1-,LC
• z1ed4/15. j3c3.j)/
CompaayName '1d INNERCABINGOR G(aea8ramalelaaed-IoaD)'. '
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FROM TO. . DIa1lAK 7R : TBIC 49• MATERIAL
'2.:Wdl ConstmcHun Peanut# cube;a b (D a.` R ft, : 'li ..ia.: • . : . • • : .
-:lin al/applicable Weil cceistruction permits(te County,State,Variance,etc.)
. :3.Well Use(cheek well use): • ' : : .
. . . . . . . . . . . .. 17.SCREEN
.: Water Snpplj!,VPeIL• . .
BROM . TO. DIAMETER SLOT ffiZE THICKNESS MATERIAL •
DAgucultur:l ❑ ,�,�;�p-aIsPuiblic ft . . ft
:DGeothetmal(Heating/Cool ng•Supply) • tia1 Water Supply(fie): ft ft" • • ui; • .
Ole shial/Commeroiil : ' • ORardential Water S 18.GROUT -
M TO MATEttiAl:` El►lPI:ACEttffiQCMBTHODdcAMO17Ni
• ohngaate •, .. • 0•; ' ft . 20 ft Concrete • Gravipr-Flow::; .i
. . Nan w�iters�r�swm•: � . ' . •
OlVtonitoring ORecovery . fa • ft. • 5
• . Injection Well: • . . ft• ft ' ,: ' 202d '
OAquifer Rei hAtge : • OGroundivater•Remediatioa' . '19.SAND/GRAVEL PACK(dame) : • '•• '• • . • • • • '
• FROM. TO, .: MATEL2IAL' IIsII+LACEb�dTMETHOD'. . 1
OAquiferStorage,andRecovery •OSalmityBarrier:' • ft . �. ,�,,.,y�,«•+�,,, .,.mow:.;}1r.I
. OAquifer Test. . OStormwaterDrainage _ ' . •D1fdCi, •�" • •
DExperimental Technology. • • ,OSubsidence Control • • . • , . , . . . . i . r
• CiGeuthennal(Closed Loop) ' • OTracer PROM �T LOG.(attadtDFaFa Ohs :....
ON(Cubar,hardness,wlUroclt type,Curia da4 eft)
OGeothi mal(Heating/Cooling Return) .• DOther(explain under#21 Rmrarks) •.:G7 :ft. 7f .ft • • .
4:Date Well• s)Com Cued: ' Weu m#
Sa. •WdlLocation: .
Sc.r w kri vj . . • .ft. • . . ft. . .
Faci(ity/OwnerNamc. • ' .Famlity lD#(if applicable)
• • ; .12 cl •'L(C•C'S'`Pr gh 1 • .ft: • . ft
FhysicEl Address,'City;and Zip 21.RE11lARK6
(Ant,rife to 4p,i vd bo, . . . . .
County Paine!Identilloation No.(PIN).
5b.Latitude and Longitude in degrees/ utedieconds'or decimal'degrees: •
(ifwon Sold,one latllong is sufficient) 22.•Certification•, • I
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Si W CoatfaE r Dale
• ::: 6•Is(ere):theweII(e):: ermaneat. or OTemporaay ••. •• , ' • '• .By slgrmrg this;jam'l hereby certify!.tfiat:ilie wet! wds(were)'cauiructid fii accoiplawe
• with 15ANCAC 02C.0100 or 1SANCAC,02C.0200 Weil ConshrtrcionStandarrlt and that a
7.Is thIs a repiir•to an existing wcl: OYes .or • C10 . . • . copy ofthus record has been provided to the well Owner.. .• • . . . . • . .
•:,(f this ir a repair,fill out known well eonsbnetion inic,romdion and pilot);the natwe of the • . • • . • . .
•• rspairunder#21 rmaarksseetion oron the beickcf thtsfanx ' 23.•SIte•diagram or additional well details: ,
' • • : :You may use the back of this page to provide additional well site details or well
S.•Number of wells constructed:: ' •'• !. ' .. • • • constmdion details:.You may also attach additional pages if necessary. • '
tteeettai3Ornoti4tilei;Ait,oply wells WY:with.the stone eetistivtetiott,xiott,youcan S •
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subimt aufams=
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9:Totaltvell depth belowlind'sarface: • T ..S • • (ft.) tea. For MI Wells: Submit this:form Within 30 days of'completion'of welt •
Formultiple we ie list oidept is if#fferort(example-3@2(10'Om!24100'),• construction to'the following: I • .:' - '' :
•'• .10:Static water lend below top of casino' A (ff.) . •• Division of Water Quality,Wormation Processing Unit, . • , •
• ,(fwata.levelts above casing use"4." • -1617 Mail Service Center,Raleigh,NC 27699-1617:
.11.Borehole•diameter. ••f` CQ • (m)' • • • • 24b For inieeliolt Well* ]n addition to sending the form to the address in 24a •'
' • above, also submit se•copy of this:form within 30 days:-of completion•of well:
12.. " constructionmethod.
ROtary • • • •construction to,the following
(LE,auger rotatyi•'.Cable,dm• et push,Etc.) •• . . . . . . Division •of Water •Quality,U. rgroun Injection Control.. Paagram,
' Censers Raleigh,NC 27699-1636• . '
FOR WATER SUPPLY WELLS ONLYd. 163611SeII Service
• • Blowing-Rig • .24e.For Water Srmnly&Inieet eWellsrIn:addition'tosending.theformto. • : •.
13a.Yield(glum) . ' . ' Method of•teste co•py •of this.foam "thin days of
-• •. . . e.addres
• 13fi Disinfection type:;Chlorine: Ararat: • .oz,:. completion. . the county .• . •
s(es ••oho' also submnit
of:well'coastructiau to health deparanent•of the county
:Where • • 1
• t .• RevisedJau.•2A13. '
Form CW 1 Nori Carolina DopaKpient of Envimnnmat Cad Natural Resoruees=D+visioa of Waler.Qu+�lriy